HIV ISSUES IN SOUTHEAST EUROPE: A CRITICAL TIME FOR
ACTION
Sue Simon1
Editorial
There is a need for bringing service providers, advocates and HIV-affected communities together in the Western Balkans and Albania to address HIV/AIDS prevention concerns and to network around shared strategies and resource development. While thankfully, HIV-infection rates in the region have (for the most part) remained low in comparison to places like Russia, Ukraine or Belarus, there are multiple factors that render Southeast Europe at risk for a significantly expanded HIV epidemic. These include severely depressed economies (widespread unemployment and expanding poverty), a highly mobile population due to years of conflict (large numbers of refugees and internally displaced persons), and government instability (leading to reduced social welfare and ineffective health care services). Without appropriate HIV prevention, treatment and care measures, an already difficult situation is likely to grow worse.
There are multiple challenges in Macedonia, Albania, Serbia, Montenegro, Croatia, Bosnia and Kosovo to secure the appropriate financing, quality and quantity of HIV prevention, treatment and care services to address the needs of socially marginalized populations. External donor funds (from private foundations and bi-laterals) in this region have become progressively less available. For the most part, national governments remain unable or unwilling to provide adequate resources to bring prevention, treatment and care efforts to scale. Macedonia, Serbia and Croatia are the only countries to have (small) Global Fund grants, but the percentage of Global Fund resources targeting the prevention needs of vulnerable populations is far from adequate. EU funding for "new neighbors" targeting HIV and/or socially marginalized groups has not materialized as had been the hope, and even those countries in line for EU accession will not necessarily be able to make the needed improvements in their health care infrastructure.
This is the bad news—and indeed, it is a precarious situation.
The good news is that Slovenia has emerged as a regional best practice hub for harm reduction and drug
treatment efforts, particularly in terms of replacement therapy. There is excellent capacity in Slovenia for hosting study tours and convening practitioners and advocates from across Southeast Europe, such as the recent conference in Kranjska Gora, Slovenia. Needle exchange and other harm reduction efforts have taken hold in Macedonia, Albania and Croatia. We have seen the emergence of strong providers and advocates, including growing numbers of affected community members (e.g., people living with HIV/AIDS, drug users, prison groups) who are involved in vital service delivery and advocacy efforts. Long isolated, Serbia and Montenegro are now building up their capacity to address the HIV needs of socially marginalized populations through the HIV Prevention Among Vulnerable Populations Initiative (HPVPI).
Research has shown that windows of opportunity to stop, slow or even stabilize an HIV epidemic in countries with low prevalence rates are small. Thankfully, the UK Department for International Development (DfID) provided $2.3 million for a cohesive program of evidence based HIV prevention interventions targeting vulnerable populations in Serbia and Montenegro. Implemented in May 2004 by Imperial College and the Open Society Institute, in collaboration with the Republican AIDS Commissions (RACs) of Serbia and Montenegro and the United Nations Development Program (UNDP), it is anticipated that HPVPI will serve as a model for effective HIV prevention strategies in the South Eastern European region.
The first phase of HPVPI encompassed a broad assessment of HIV needs and priorities in Serbia and Montenegro. This included an analysis of opportunities and obstacles related to laws, policies and the social environment. More than 100 interviews and discussions were held with government officials, members of the RACs of Serbia and Montenegro, people living with HIV/ AIDS, and representatives of agencies and institutions with a current or future potential involvement in HIV prevention efforts targeting vulnerable populations. Out of these myriad consultations, the implementation phase of HPVPI was designed.
iOpen Society Institute, Sexual Health and Rights Program (SHARP), 400 West 59th Street, New York Correspondence to: e-mail: ssimon@sorosny.org
HPVPI encourages sustainability by combining support for HIV prevention projects with outputs in advocacy, capacity-building, network building and evaluation. The project Secretariat, housed within UNDP, collaborates closely with government ministries, the RACs, state services, the NGO sector and international communities. Further, HPVPI encourages innovation not only by focusing on direct service provision to vulnerable populations in urban and rural areas but also by encouraging community organization, policy/ advocacy, and integrating HIV prevention into a framework cognizant of the human rights and social welfare needs of vulnerable populations. The Initiative encourages an evidence-based approach by integrating the development of HIV prevention demonstration projects with thoughtful monitoring and evaluation from the outset.
In countries that have a strong foundation of HIV/AIDS prevention, treatment and care services, it has been easier to develop a supportive public policy arena in which punitive drug laws and policing, combined with a dearth of health and social welfare services for vulnerable populations (including drug users, sex workers, prisoners, and people with HIV/AIDS) cease contributing to public health problems at the same time as depriving individuals of their basic human rights. It is hoped that HPVPI will have a measurable impact and that lessons learned will impact prevention, treatment and care strategies in Southeastern Europe and beyond.
Other hopeful news: Albania will soon be launching the first community-based methadone program in Eastern Europe. Croatia's system of General Practitioner-based methadone prescription is seen as a leading model by drug treatment experts around the world. With increasing frequency, human rights and legal service organizations are joining forces with more traditional harm reduction stakeholders to take on drug policy and discrimination issues. Police have been trained on harm reduction
strategies in Albania and Macedonia and improved relationships between law enforcement, drug users and their advocates have been developed. Special services targeting the most vulnerable groups at risk for HIV (encompassing injecting drug users, sex workers, Roma communities, prisoners and MSM (men who have sex with men) have started up in several countries.
Best of all, we are seeing a burgeoning effort among harm reduction stakeholders to network and support one another throughout the region. Where previously there had been few linkages across borders, we now see relationships being forged and resources shared. The provision of technical assistance from more experienced to less experienced projects has become locally driven-for example, the leading harm reduction expert from Macedonia mentors start-up needle exchange programs in Serbia and Montenegro; the most experienced replacement therapy provider from Slovenia provides hands-on support to his colleagues in Albania. In 2004, a conference entitled, Vanguard: Youth Forum on Reducing Drug Related Harm and HIV was held in Belgrade and all countries in SEE sent representatives.
Building on Vanguard, efforts are currently underway to establish a network in Southeast Europe of stakeholders concerned about HIV prevention, treatment and care issues among socially marginalized communities. This initiative will unite advocates, service providers and affected people from across the region to promote cross-border initiatives, joint advocacy activities and resource sharing. Two successful planning meetings have already been held-the first at the International Harm Reduction Conference in Belfast and the second at the Replacement Therapy Conference in Kranjska Gora, Slovenia. Funds have been raised to support the initial organizing costs for the network. In a region that has long been filled with conflict, the HIV services and harm reduction communities have begun to establish extraordinary bonds to great effect.
VPRAŠANJE OKUŽB Z VIRUSOM HIV V JUGOVZHODNI EVROPI:
ČAS ZA UKREPANJE
Sue Simon1
Na podro~ju zahodnega Balkana in Albanije je potrebno na podro~ju prepre~evanja okužb z virusom HIV dose~i sodelovanje ~imve~jega števila zdravstvenih delavcev, interesnih skupin in skupin prebivalstva, ki jih ogrožajo okužbe z virusom HIV. Skupaj morajo oblikovati smernice za delo in razvoj virov. Čeprav je na sre~o število okužb z virusom HIV na tem podro~ju (ve~inoma) sorazmerno nizko v primerjavi z državami, kot so Rusija, Ukrajina in Belorusija, jugovzhodni Evropi še vedno grozi nevarnost zelo obsežne epidemije okužb s HIV zaradi številnih dejavnikov. Sem sodijo obubožano gospodarstvo (visoka nezaposlenost in širjenje revš~ine), izredna mobilnost prebivalstva zaradi ve~ let trajajo~ih konfliktov na tem podro~ju (številni begunci in notranje preseljevanje prebivalstva) in nestabilnost vlad, zaradi ~esar se manjša družbena blaginja in u~inkovitost zdravstvene službe. Brez ustreznih ukrepov za prepre~evanje in zdravljenje okužb z virusom HIV se bo ta težki položaj verjetno še poslabšal.
V Makedoniji, Albaniji, Srbiji in Črni gori, na Hrvaškem, v Bosni in na Kosovu številni dejavniki vplivajo na zagotavljanje ustreznega financiranja, na število in kakovost ukrepov za prepre~evanje okužb z virusom HIV ter na skrb za obrobne skupine prebivalstva. Sredstva, ki jih prispevajo zunanji darovalci (zasebne ustanove in bilateralni viri), se v teh državah vedno bolj manjšajo. Vlade ve~inoma ne morejo ali no~ejo zagotoviti zadostnih sredstev, potrebnih za ustrezno prepre~evanje, zdravljenje in nego. Makedonija, Srbija in Hrvaška so edine države, ki lahko ~rpajo (skromna) sredstva Globalnega sklada. Delež sredstev tega sklada, namenjen prepre~evalni dejavnosti med ogroženimi skupinami prebivalstva, pa je veliko premajhen. Zagotavljanje sredstev EU za »nove sosede«, ki so namenjena okužbam z virusom HIV oz. obrobnimi skupinam prebivalstva, ni potekalo v skladu s pri~akovanji. Tako celo za države, ki ~akajo na sprejem v EU, ni povsem gotovo, ali bodo zmogle izvesti vse potrebne izboljšave v zdravstveni infrastrukturi.
Te napovedi so slabe in položaj je zelo negotov.
Dobra novica pa je ta, da je postala Slovenija regijsko središ~e z najboljšimi dosežki na podro~ju
Uvodnik
zmanjševanja škode in zdravljenja odvisnosti, predvsem na podro~ju substitucijskega zdravljenja. Slovenija ima zato odli~ne možnosti za organiziranje študijskih sre~anj zdravnikov in drugih strokovnjakov iz jugovzhodne Evrope. Sem sodi tudi nedavna konferenca v Kranjski Gori. Oskrbo z iglami in druge ukrepe za zmanjševanje škode so uvedli tudi v Makedoniji, Albaniji in na Hrvaškem. Oblikovale so se u~inkovite skupine izvajalcev in njihovih sodelavcev, ki vklju~ujejo vse ve~je število prizadetih skupin prebivalstva (okuženi z virusom HIV, bolniki z aidsom, uživalci drog, zaporniki), ki sodelujejo v najpomembnejših dejavnosti na tem podro~ju. Srbija in Makedonija, ki sta bili dolgo mednarodno osamljeni, sta z vklju~itvijo v program »Prepre~evanje širjenja virusa HIV med ranljivimi skupinami prebivalcev« (HPVPI - HIV Prevention Among Vulnerable Populations Initiative) za~eli reševati problem okužbe z virusom HIV med skupinami prebivalcev, ki žive na družbenem obrobju .
Raziskave so pokazale, da so možnosti za zaustavitev, upo~asnitev ali umiritev epidemije HIV v državah z nizko stopnjo okužb z virusom HIV, majhne. Pohvalno pa je, da je Oddelek za mednarodni razvoj Velike Britanije (DfID) namenil 2,3 milijonov funtov za kohezivni program preventivnih dejavnosti med ogroženimi skupinami prebivalcev v Srbiji in Črni Gori. Pri~akujemo, da bo program HPVPI, ki sta ga izpeljala v maju 2004 Imperial College in Institut za odprto družbo (Open Society Institute) v sodelovanju z republiškimi odbori za aids Srbije in Črne Gore, s pomo~jo Razvojnega programa združenih narodov (UNDP) služil kot model za u~inkovito prepre~evanje širjenja okužb z virusom HIV na podro~ju jugovzhodne Evrope.
V prvi fazi HPVPI so ocenili potrebe in dolo~ili prednostne naloge na podro~ju okužb z virusom HIV v Srbiji in Črni Gori. Opravljena je bila tudi analiza možnosti in težav, povezanih z zakonskimi dolo~ili, politiko in družbenimi dejavniki. Opravili so ve~ kot sto pogovorov in razprav z vladnimi predstavniki, ~lani republiških odborov za aids Srbije in Črne Gore, s posamezniki, okuženimi z virusom HIV, z bolniki z aidsom in s predstavniki agencij in ustanov, ki
iOpen Society Institute, Sexual Health and Rights Program (SHARP), 400 West 59th Street, New York Kontaktni naslov: e-pošta: ssimon@sorosny.org
sodelujejo ali nameravajo sodelovati v dejavnostih za preprečevanje okužb med ogroženimi skupinami prebivalcev. Na osnovi teh številnih posvetovanj so nato oblikovali izvedbeno fazo HPVPI.
HPVPI spodbuja države, naj zagotovijo trajnost teh dejavnosti tako, da povežejo projekte za preprečevanja širjenja okužb z virusom HIV in rezultate dosežene na področju skrbi za odvisnike, usposabljanja, oblikovanja mrež in ocenjevanja. Tajništvo projekta v sklopu UNDP tesno sodeluje z zveznimi ministrstvi, republiškimi odbori za aids, državnimi službami, nevladnimi organizacijami in z mednarodno skupnostjo. HPVPI spodbuja uvajanje novih pristopov, ne le na področju neposredne skrbi za ogrožene skupine v mestnem in podeželskem okolju, temveč tudi pri organiziranju skupnosti, politike in interesnih skupin: dejavnosti, povezane s preprečevanjem širjenja okužb z virusom HIV pa umešča v okvir spoštovanja človekovih pravic in zagotavljanja potreb ogroženih skupin prebivalstva po družbeni blaginji.
HPVPI spodbuja dejavnosti na osnovi podatkov, podprtih z dokazi, ki vključujejo razvoj demonstracijskih projektov s področja preprečevanja okužb z virusom HIV in natančno spremljanje in ocenjevanje rezultatov od samega začetka izvajanja programa.
V državah, kjer so preprečevanje širjenja okužb z virusom HIV ter zdravljenje in nega bolnikov z aidsom že dobro utečeni, je bilo laže oblikovati javno podporno politiko, ki z ustrezno kazensko zakonodajo in policijskim delom na področju uporabe prepovedanih drog ob pomanjkljivi zdravstveni in socialni skrbi za ranljive skupine prebivalcev (odvisniki, prostitutke, zaporniki in okuženi z virusom HIV, bolniki z aidsom) ne povečuje več javnih zdravstvenih problemov in ne krati osnovnih človekovih pravic. Upati je, da bodo učinki HPVPI opazni in merljivi in da bodo pridobljena spoznanja vplivala na strategijo preprečevanja, zdravljenja in nege v jugovzhodni Evropi in drugod.
Upanje zbuja še ena novica: Albanija bo kmalu uvedla prvi javni metadonski program v vzhodni Evropi. Po mnenju strokovnjakov za zdravljenje odvisnosti z vsega sveta je trenutno najboljši hrvaški model predpisovanja metadona v ambulantah splošnih zdravnikov. Organizacije za zaščito človekovih pravic in pravne ustanove pri reševanju vprašanj, ki se nanašajo na
uporabo prepovedanih drog in razlikovanje, vedno tesneje sodelujejo z že uveljavljeno mrežo za zmanjševanje škode. Izobraževanje policistov v Albaniji in Makedoniji je bilo posvečeno spoznavanju smernic za zmanjševanje škode in izboljševanju odnosov med zaposlenimi na področju odkrivanja in pregona, odvisniki od prepovedanih drog in tistimi, ki skrbe za odvisnike.
V	več državah so že uvedli posebno službo, ki skrbi za družbene skupine, med katerimi je ogroženost za okužbo z virusom HIV največja; sem sodijo odvisniki, ki si droge vbrizgavajo, prostitutke, romske skupnosti, zaporniki in homoseksualci.
Najbolj razveseljivo pa je videti, da se na tem področju živahno povezujejo vsi, ki delajo na področju zmanjševanja škode. Povsod tam, kjer so bile prej čezmejne povezave šibke, zdaj tkejo nove vezi in si med seboj delijo razpoložljiva sredstva. Zagotavljanje tehnične pomoči bolj izkušenih tistim, ki imajo manj izkušenj, poteka na lokalni ravni; tako npr. vodilni strokovnjak za zmanjševanje škode iz Makedonije uvaja program razdeljevanja igel v Srbiji in Črni Gori, najbolj izkušen strokovnjak na področju nadomestnega zdravljenja iz Slovenije nudi praktično pomoč kolegom v Albaniji. Leta 2004 je potekala v Beogradu konferenca z naslovom »Avantgarda: Mladi forum za zmanjševanje škode zaradi odvisnosti od drog in okužbe z virusom HIV (Vanguard: Youth Forum on Reducing Drug Related Harm and HIV), na katero so svoje predstavnike poslale vse države jugovzhodne Evrope.
Na osnovi teh smernic potekajo dejavnosti za oblikovanje mreže vseh interesnih skupin, ki se na področju jugovzhodne Evrope ukvarjajo z vprašanji preprečevanja širjenja in zdravljenja okužbe z virusom HIV med družbeno odrinjenimi skupinami prebivalcev.
V	tej akciji bodo sodelovali vsi, ki se ukvarjajo z odvisniki, zdravstveni delavci in prizadeti posamezniki s celotnega področja. Spodbujali bodo čezmejno sodelovanje, skupno podporo odvisnikom in skupno izrabo virov. Za nami sta že dve uspešni srečanji, prvo v času Mednarodne konference o zmanjševanju škode v Belfastu, in drugo med Konferenco o substitucijskem zdravljenju, ki je potekala v Kranjski Gori. Zagotovljena so bila sredstva za začetne stroške pri organiziranju mreže. Na področju, kjer so dolga leta potekali spopadi, so skupine, ki skrbe za zmanjševanja škode in preprečevanje širjenja okužb z virusom HIV, začele učinkovito tkati trdne medsebojne vezi.