Central Europe must respond to the threat of a new disaster.
HIV is spreading faster than ever and the virus knows no border.
The figures on victims are modest when compared to those of subSaharan Africa. They are not in the millions. But an explosive epidemic of HIV/AIDS is underway in Central Europe and Central Asia and only an upscale programme of prevention and care can avert another catastrophe. Already the scale of the Central Asian crisis resembles that of Africa in the early 1980s.
This was the picture to emerge from the fifth annual conference of the European Red Cross and Red Crescent Network on HP//AIDS PS (ERNA) in Almaty, Kazakhstan. National Societies reported an unprecedented growth in HIV, and while official rates in some countries are increasing threefold and fourfold annually, reality is thought to be much worse.
The AIDS virus is showing a “threatening new trend”, the meeting was told, and ERNA’s chairman, Dr Massimo Barra, was moved to conclude, “We are not on the verge of a crisis. We are in one.” Worst hit are the countries along the heroin highway that extends from Afghanistan, north through Central Asia to Russia, then west into the Baltic region, where Estonia and Latvia are severely affected, and Central Europe.
Intravenous drug use is the major cause of HP! growth here, and Latvia reports that 82 per cent of new infections now concern drug users. The flow of drugs, meanwhile, is ever greater. Along the corridor from Afghanistan labeled the Silk Road by law enforcement agencies, a reference to the historic trade route that once channeled Asian textiles and spices to Europe growing traffic is evident in by authorities. 1992, Tajikistan confiscated 38 kilos of poppy paste; by September this year alone they had netted nearly seven tons.
The number of addicts grows proportionately, particularly among the young. More than 800,000 drug addicts are recorded across the Central Asian region, says the Joint United Nations Programme on HP//AIDS (UNAIDS), young people more and more prominent among them. And an assessment commissioned by the International Federation’s Regional Delegation in Budapest speaks of an “epidemiclike drug addiction that is sweeping through the youth of Central Europe”. The assessment corroborates ERNA’s reports. Amongst the evidence of crisis:
• HIV is soaring in Estonia with 1,131 new cases in the first eight months of this year compared to 390 in 2000 and just 12 in 1999. Through the second half of the 1990s it averaged a mere 10 new cases a year.
• Latvia’s new infections nearly doubled in 2000, to 466. By September 1 this year, 547 more cases had been recorded.
• It brought the Latvian cumulative total to 1,505 among a population of 2.4 million, although some health experts say the real number of infections could be three times higher.
• Both Latvian and Estonian new cases were mainly among intravenous drug users (IDU5). Most of Estonia’s are in the northeastern region bordering Russia, where drug abuse is most chronic.
• Most Estonians diagnosed in 2000 were between 18 and 24, the youngest just 13 years old. In a world now used to shocking infection rates like Botswana’s 36 per cent of the adult population, such statistics do not command the spotlight. They should. Expert opinion is united in saying that all 15 Central European countries are at risk, and major prevention programmes are crucial.
Mapping the risk
Analyzing the means of HIV transmission, the Federation assessment says three large geographical areas can be mapped. In the north (in Estonia, Latvia, Lithuania, Poland), most infected people are IDUs. In the centre (in the Czech Republic, Slovakia, Hungary, Slovenia, Croatia), most are homosexuals, and in the south (Bulgaria, Albania, Macedonia. Romania), transmission is mainly heterosexual. Romania, however, which had the region’s highest official HP/incidence at the end of last year (47 per 100,000 inhabitants), faces an essential difference.
Much of the transmission has been through blood transfusions and this has particularly affected children, giving the country more than 50 per cent of Europe’s pediatric AIDS cases. Drug use presents the greatest risk of rapid expansion of the virus and AIDS activists in Estonia, for example, fear the IDU epidemic will soon spread into the general population, following patterns elsewhere. The dangers are clear.
The overwhelming majority of IDUs in the region report the sharing of syringes, injecting from a common container and adding blood to the drug mixture they prepare. Unsafe sex, commonly associated with drug use, is also evident. The majority says they rarely use condoms. But IDUs are not the only socially excluded groups among people most vulnerable to HP!. As well as homosexuals and sex workers, the Federation assessment includes the homeless, street children, and minorities especially unemployed Roma youth in the highrisk category.
Romanian AIDS consultant, Dr Oana Vasiliu, who compiled the assessment, says that with the economies of many countries continuing to crumble, and unemployment high, the young are becoming more vulnerable. “They increasingly rely on alternative sources of economic and emotional sustenance,” she says. “Many escape into alcoholism and drug use; others turn to the streets, to commercial sex and to crime to earn money for their needs.”
In Romania, says Dr Vasiliu, an estimated 2,000 to 5,000 children work or live on the streets, exposed to sexual abuse, exploitative work and violence. “For them,” she says, “key relationships tend to be with other children who use drugs and engage in prostitution.”
Peer to peer
For the 22 Red Cross and Red Crescent National Societies under the ERNA umbrella, the prime focus is on awareness raising and prevention programmes, and the young in particular are targeted. Red Cross Youth have taken the lead in many societies and significantly in Almaty an ERNA conference was attended by youth representatives for the first time.
Peertopeer education is central to their efforts and two days were set aside for a youth peer education workshop. Marcel Stefanik, President of the Slovakian Red Cross Youth, called for ongoing innovation. “If we want to get the message across we have to go beyond tedious lectures, discover new approaches,” he said. Working through schools, colleges, clubs and other meeting places, Red Cross Youth has shown peertopeer programmes to be the most efficient means of reaching young people. “It isn’t only about knowledge,” said Dr Vesna Durovic, health coordinator of the Federation’s Bosnia and Herzegovina delegation.
“Health promotion is a question of ownership and young people relate to other young people best, and are more open to them. Everyone needs to understand this if we are to make a significant impact on attitudes and behavior.” Red Cross Youth, meanwhile, is emphasizing the need for its full participation in the design and evaluation of services, as well as in delivery. It isn’t only youth that undertakes peer education, and ERNA chairman Barra called for recovered drug addicts to work with IDUs.
They had been key to success in Italy where HJV incidence among intravenous users has been halved in recent years. “Firsf of all,” he said, “we need people out there spreading the word about how to use drugs cleanly.” Others want gay educators working the gay social scene, and prostitutes advising prostitutes. “How people live their lives is none of our business,” said a National Society doctor “Our concern is that they live them safely.”
Harm reduction
Federation policy on harm reduction, as opposed to prevention, has yet to be formed. There is no consensus but National Societies pursue their own directions, as in Latvia which has seen a rapid increase in HIV infection since 1998. when the number of reported cases jumped to 163 from 25 the year before.
The high incidence among drug addicts has persuaded the Latvian Red Cross that harm reduction programmes of needle exchange and methadone distribution are absolutely vital, and they have gone hand in hand with information campaigns. “We must do more,” commented National Society adviser, Dr Inga Upmace. The Red Cross already collects 6,000 used syringes a month from addicts in Riga, and by the end of the year there will be up to eight new services beyond the capital. Needle exchange began in 1997 and 24 percent of those supplied are HIV positive.
There are signs of improvement. Says Dr Upmace. “The incidence of HW was increasing every month but for several months now new cases have been held at around 18 per cent. Everything depends on prevention, on school and youth education. We must counter the temptation to try drugs. We can talk and talk but unless people understand how serious it is to pick up a syringe we will not stop this epidemic.”
Even in countries where no upward spiral is evident, there is realization of an urgent need for expanded prevention. Dr Veneta Mihaylova Vassileva of the Bulgarian Red Cross is concerned that a modest 300 official cases of HIV in her country give the population a false sense of security.
Specialists believe the real figure is at least 10 times that, and she commented, “The figures I heard in Almaty are frightening because one day they will be reported from Bulgaria, too. The Balkans may not be at the epicenter now but that does not mean we will be passed by.”
Sexual contact is the main means of transmission in Bulgaria, and Dr Vassileva’s fears for HIV are further fuelled by the high rate of other sexually transmitted infections. She speaks of “a boom” in syphilis and hepatitis B, and experience shows that where STIs gain ground HIV/AIDS is not far behind. Besides reflecting unsafe sexual behavior, STIs provide conduits for the AIDS virus through inflammations and lesions.
Need for advocacy
Dr Vassileva insists this is a critical moment for raising awareness and bolstering prevention. But while the Red Cross invests in more programmes there is also a burning need for private advocacy towards the authorities. The Federation survey reveals many shortcomings in state legislation, procedures and education, and stigma and discrimination against people living with HIV and AIDS must be confronted. Discrimination is more than a violation of human rights, the Federation says.
It discourages people from being tested, leaves them unaware of their HIV status, and unwilling to accept or discuss it. Governments likewise bury their heads in the sand. Worldwide, stigma is contributing to millions of deaths and new infections. While testing is anonymous in Central Europe with the exception of Hungary which requires a declaration of positive status confidentiality is routinely violated by medical personnel, Dr Vasiliu found.
Testing is not encouraged by health workers, either, and the majority particularly doctors and nurses provide inadequate HIV counseling. Sexual education that covers STIs is mandatory in schools in most of the region but the evidence is that many curricula exclude it. A 1998 survey in Estonia, for instance, showed that only 1.5 per cent of teachers talked about sex and AIDS with their students. Elsewhere teachers are not trained, or lack necessary knowledge, and is presented from a religious viewpoint.
A state evaluation of sex education in Poland rated a decrease in condom use as a positive factor. Red Cross Youth in the region believes some Christian educators provide misinformation to pupils. Competent NGOs are involved in HIV/AIDS prevention but most operate in the capitals, allocated time is insufficient to make an impression, and available surveys show that while studentsÕ knowledge is good it does not translate into preventive behavior. Few if any state or NGO programmes target the most vulnerable. It is time, concludes ERNAÕs Dr Barra, to reassess policy Fast.
Compiled by Ingrid Udden, Regional Health and Care Delegate; Dr. Vesna Durovic, Federation Health Programme Manager, Bosnia and Herzegovina; and John Sparrow.
Network on AIDS
A critical need for preventive HIV programmes. psychological support and care for people living with the virus, and the defence of human rights, brought 12 National Societies together in Rome in 1998. What was required, they determined, was a body to coordinate the sharing of experience, the transfer of best practice and the promotion of collaborative Red Cross and Red Crescent efforts in the European region.
Today some 22 National Societies from Western, Central and Eastern Europe, and from Central Asia, are gathered in the European Red Cross Red Crescent Network on HIV- AIDS (ERNA). The common objective: to prevent the spread of the virus principally among the most vulnerable people. Says its chairman, Dr Massimo Barra of the Italian Red Cross, “Our movement could not be more suited to such an undertaking.
With our national networks nowhere is beyond reach, and our concern for health, human rights and dignity earns the trust of even the most marginalized.” Dr Barra, whose own work is among ItalyÕs drug addicts, is urging more Western European societies to join ERNA. For full information contact Zina Ankova, Programme Coordinator, ERNA Secretariat, Slovak Red Cross, Grosslingova 24,81446 Bratislava. Tel: +421 752932927. Fax: +421 752923279. Email: erna… secretariat@yalioo.c