The global picture

THE joint United Nation programme on HIV/AIDS, UNAIDS and the World Health Organisation launched the “AIDS epidemic update: December 2005” on November 21. According to the report, Acquired Immunodeficiency Syndrome (AIDS) has killed more than 25 million people since it was first recognised in 1981, making it one of the most destructive epidemics in recorded history. Despite recent, improved access to antiretroviral treatment and care in many regions of the world, the AIDS epidemic claimed 3.1 million (between 2.8 and 3.6 million) lives in 2005, more than half a million of which were children. The total number of people living with the human immunodeficiency virus (HIV) reached its highest level: an estimated 40.3 million (between 36.7 and 45.3 million) people are now living with HIV. Nearly five million people were newly infected with the virus in 2005.

The report says that there is ample evidence that HIV does yield to determined and concerted interventions. Sustained efforts in diverse settings have helped bring about decreases in HIV incidence among men who have sex with men in many Western countries, among young people in Uganda, among sex workers and their clients in Thailand and Cambodia, and among injecting drug users in Spain and Brazil. Now there is new evidence that prevention programmes initiated some time ago are finally helping to bring down HIV prevalence in Kenya and Zimbabwe, as well as in urban Haiti.

However, the number of people living with HIV has increased in all but one region in the past two years. In the Caribbean, the second-most affected region in the world, HIV prevalence overall showed no change in 2005, compared with 2003. Sub-Saharan Africa remains hardest-hit, and is home to 25.8 million (between 23.8 and 28.9 million) people living with HIV, almost a million more than in 2003. Two thirds of all people living with HIV are in sub-Saharan Africa, as are 77 per cent of all women with HIV. An estimated 2.4 million (between 2.1 and 2.7 million) people died of HIV-related illnesses in this region in 2005, while a further 3.2 million (between 2.8 and 3.9 million) became infected with HIV. Growing epidemics are underway in Eastern Europe and Central Asia, and in East Asia.

AIDS responses have grown and improved considerably over the past decade. But they still do not match the scale or the pace of a steadily-worsening epidemic. In the past two years, access to antiretroviral treatment has improved markedly. It is no longer only in the wealthy countries of North America and Western Europe that people in need of treatment have a reasonable chance of receiving it. Treatment coverage in countries such as Argentina, Brazil, Chile and Cuba now exceeds 80 per cent. Despite progress in some places, however, the situation is different in the poorest countries of Latin America and the Caribbean, in Eastern Europe, most of Asia and virtually all of sub-Saharan Africa. At best, one in 10 Africans and one in seven Asians in need of antiretroviral treatment were receiving it in mid-2005. However, over a million people in low-and middle-income countries are now living longer and better lives because they are on antiretroviral treatment. Because of the recent treatment scale-up since the end of 2003, between 250 000 and 350 000 deaths were averted in 2005. The full effects of the dramatic treatment scale-up during 2005 will only be seen in 2006 and subsequent years. Indications are that some of the treatment gaps will narrow further in the immediate years ahead, but not at the pace required to effectively contain the epidemic. It has long been recognised that gaining the upper hand against AIDS epidemics around the world will require rapid and sustained expansion in HIV prevention. In fact, the goal must be to ensure that countries everywhere come as close as possible to achieving universal access to HIV prevention, treatment, care and impact mitigation. Achieving universal access will require co-ordination of different approaches. Prevention, treatment, care and impact mitigation goals will have to be pursued simultaneously, not sequentially or in isolation from each other. Countries will need to focus on programme implementation, including strengthening of human and institutional resources, and initiate strategies that allow for the greatest possible level of integration of services. All of this must be done with great urgency. But it forms part of a larger, more long-term challenge. Bringing AIDS under control will require tackling with greater resolve the underlying factors that fuel these epidemics-including societal inequalities and injustices. It will require overcoming the still serious barriers to access that take the form of stigma, discrimination, gender inequality and other human rights violations. It will also require overcoming the new injustices created by AIDS, such as the orphaning of generations of children and the stripping of human and institutional capacities. These are extraordinary challenges that demand extraordinary responses.

Eastern Europe and Central Asia

According to the report, the steepest increases in HIV infections have occurred in Eastern Europe and Central Asia and are affecting ever-larger parts of societies in this region.

The number of people living with HIV in Eastern Europe and Central Asia has increased by one quarter (to 1.6 million) since 2003, and increased nearly twentyfold in less than 10 years. The number of AIDS deaths almost doubled, to 62 000, between 2003 and 2005.
The widening impact on women is also apparent in Eastern Europe and Central Asia, many of them acquiring HIV from male partners who became infected when injecting drugs.

Across Eastern Europe, Asia and Latin America the epidemics are propelled by combinations of injecting drug use and commercial sex. The report says that only a handful of countries are making serious-enough efforts to introduce programmes focusing on these risky behaviours on the scale required.

About 270 000 ( between 140 000 and 610 000) people in Eastern Europe and Central Asia were newly infected with HIV in the past year. The overwhelming majority of people living with HIV in this region are young. Seventy-five per cent of the reported infections between 2000 and 2004 were in people younger than 30 (in Western Europe, the corresponding figure was 33 per cent) (Euro HIV, 2005).

The patterns of the epidemics are changing in several countries, with sexually transmitted HIV cases comprising a growing share of new diagnoses.

The bulk of the people living with HIV in the Eastern Europe/Central Asia region are in two countries: the Russian Federation and Ukraine. Ukraine’s epidemic continues to grow, with more new HIV diagnoses occurring each year, while the Russian Federation has the biggest AIDS epidemic in all of Europe. Both epidemics have matured to the point where they constitute massive prevention, treatment and care challenges. HIV has consolidated its presence in every part of the former Soviet Union, with the exception of Turkmenistan (where little information is available on the HIV epidemic). Several Central Asian and Caucasian republics are experiencing the early stages of epidemics, while quite high levels of risky behaviour in south-eastern Europe suggests that HIV could strengthen its presence there unless prevention efforts are stepped up.

In the Baltic states, the epidemic continues to grow but at a slower pace than in the early 2000s. The overall numbers of reported HIV infections remain low. Nonetheless, the total number of reported HIV cases in Estonia, the worst-affected of the Baltic states, has doubled since end-2001, reaching 4442 in 2004.

Although few new HIV diagnoses are being reported in most of South Eastern Europe, drug injecting and sexual risk behaviour in several countries could favour swift HIV spread once the virus establishes stronger footholds. Worst-affected in this subregion is Romania, where new infections are attributed to unsafe sex, most of it heterosexual (EuroHIV, 2005).Generally, in Eastern Europe and Central Asia, current HIV data reflect the situation only among those people who come into contact with HIV testing programmes. As a result, not enough is known about HIV spread among people who do not interact with the authorities and/or testing services. Thus, for example, the role of unsafe sex between men in this region’s epidemics remains largely a matter for conjecture. Few studies have been conducted among men who have sex with men, who as a group face discrimination and stigma across the region. Available research points to high levels of unprotected sex, with a significant proportion of men who have sex with men also having sexual relations with women (WHO Regional Office for Europe, 2004).The total number of people receiving antiretroviral treatment almost doubled in the 12 months up to mid-2005, from 11 000 to 20 000 people, but lags far behind the number of people in need of treatment, with the largest disease burden in the Russian Federation and Ukraine.

Bulgaria- the official picture

According to statistics, as of October 15 this year, Bulgaria had 582 officially registered HIV-positive cases.

About 69 per cent of these are men, and 31 per cent women. A high percentage of newly registered cases - about 40 per cent - belong to the 20-29 age group. The youngest male registered with HIV is aged 19, and the oldest 62. The youngest registered female is 17, the oldest 54.

Although Bulgaria has low HIV/AIDS prevalence, the number of new cases of infection reported a year is increasing. So far this year, 67 new cases have been registered, this compares to 63 out of 260 000 HIV tests in 2003.Of cases registered this year, 44 were men and 23 women.

The tendency towards an increase in the number of new HIV-positive cases is accompanied by a rapid growth in the sexually transmitted infection rate, drug abuse, prostitution, and migration according to UNAIDS data. The main mode of HIV transmission is sexual, accounting for 91 per cent of all cases (88 per cent heterosexual). Four per cent of cases are a result of IV drug use and one per cent from mother-to-child transmission.

A joint project between UNAIDS and the Ministry of Health to develop a national AIDS strategy has been in place since 1988. Its aim is to promote an effective approach to HIV/AIDS and sexually transmitted infections (STIs) prevention and reduce the vulnerability of adolescents and other ‘at-risk’ groups.

The National AIDS Committee was formed in 1996 and comprises 11 ministries. It is the executive body responsible for national HIV/AIDS policy development and implementation. The National AIDS Coalition comprises 55 organisations and functions as a mechanism for broad partnership between the stakeholders in this field.

In February 2001 a National Strategy for HIV/AIDS and STIs and a National Programme for Prevention and Control of HIV/AIDS and sexually transmitted diseases 2001-2007, were adopted by the Government.

According to the National Programme, treatment of one patient in Bulgaria costs 30 000 leva a year. It lists unprotected sex and needles as the direct factors leading to HIV/AIDS. Poverty, prostitution, drug and alcohol use, low health awareness, low general education of some vulnerable groups, high (labour) mobility, lack of an overall policy for risk behaviour and HIV/AIDS spread limitation, insufficient effectiveness of institutions of agencies and services and socialisation crisis are listed as indirect factors.

In 2003, The Global Fund to fight AIDS, Tuberculosis and Malaria approved a request from Bulgaria for 15.7 million US dollars for the Prevention and Control of HIV/AIDS programme to respond to the AIDS epidemic between 2003 and 2008. The first phase of the project was granted $6 874 270. The second phase, to be launched in January 2006, has just been approved to receive $8 800 000.

The first phase of the programme included a local level response of the national AIDS strategy in 10 municipalities, where local civic committees were formed to make action plans to stop the spread of HIV/AIDS in local communities. Three hundred national and local specialists were trained in HIV/AIDS prevention to work in the Roma community, with young people, IV drug users, sex workers and homosexual men. Technical support was also provided for the establishment, operation and promotion of nine voluntary counselling and testing centres in eight towns in Bulgaria, offering free, anonymous HIV testing. Lectures on AIDS prevention and safe sex were given in 111 Bulgarian schools in 13 municipalities.

The second phase of the programme will focus on AIDS prevention in ‘at risk’ groups.

Seeking the real picture

Genko Genkov has been working with HIV/AIDS related issues since 1991, volunteering in organisations such as The Red Cross Youth and Gemini.

Concerning the discrepancy between the “official picture” and the “real picture” of HIV/AIDS in Bulgaria, he said he believed that the number of people living with HIV/AIDS (PLWHA) in Bulgaria was 10 times that represented by official statistics. He attributed this to the fact that only a limited part of the population comes into contact with HIV testing. Though, he said that this is now changing.

“The National Strategy of HIV/AIDS is increasing the number of places people can go and take tests. Three or four years ago there were probably only two places people could go, and these were only in Sofia.”

But now he said there were more testing centres and that these are free of charge and anonymous according to the law. The second problem, said Genkov, was that “typically Bulgarians don’t have a good sexual culture. Even if people have unsafe sex, their attitude is: ‘its not a problem, it doesn’t affect me, I’m somehow protected’.” Related to this is the issue that “most Bulgarians think of HIV-AIDS as a problem affecting only ‘special communities’ or ‘special kinds of people’ - which is totally untrue.”

One such ‘special community’ is of course the gay community, which Genkov said people regard as “dangerous” per se, not because of any risk behaviour associated with them. This outmoded mentality that HIV/AIDS is somehow a disease of the gay community is in stark contrast to the facts, which show that most cases in Bulgaria occur in the heterosexual community.

Nonetheless a tendency to label and to blame remains, especially among the older generation.

“Old people think God sends us [HIV-AIDS] because we are very terrible!” said Genkov.

“People’s attitude generally is very negative. They say ‘he or she is guilty, why didn’t they think before? - now it is too late’ Yes, it is too late, but it can happen to anybody. There are still a lot of prejudices about everything; about the Roma community, about drug users. So, we still have a long way to understanding the problems and showing our humanity.”

People living with HIV-AIDS in Bulgaria are faced not only with a medical, but also a social problem: stigmatisation by society. They often lose their jobs as employers would not allow for the monthly medical check-ups necessary to live with the disease.

Genkov emphasises that there is still much to be done in the way of education about AIDS, first in endorsing the “safe sex always” message, and second to communicate that “we do not have a community at risk or people at risk, we just have risk behaviour. That is the crucial point...It doesn’t really matter who you are. Really the important thing is how you take care of yourself and how you take care of the people you love, the people you respect, the people you have sex with. There is no ‘health insurance’ against HIV, everyone can be affected.”

Non-government organisations in co-operation with State are the key to this education. Genkov points to the role of the AIDS Coalition in bringing together representatives from various organisations and bodies involved in the field of HIV/AIDS and focussing their efforts constructively in following the necessary steps to reach the people.

In the fifteen years he has been working in the field, he has seen improvements in that the younger generation are now better informed, but, he said, “it isn’t enough.”

For more information, go to: www.unaids.org, www.undp.org,  www.theglobalfund.org, www.who.int