Kyrgyzstan: Reducing Harm from HIV
When he learned that he had acquired HIV from injecting drugs, 35-year-old Mirlan (not his real name) sought help from the Regional AIDS Prevention Centre in Jalalabad, Kyrgyzstan. One day in 2005, television reporters showed up with a request to film the centre’s work.
Hoping to attract attention in the press, the chief physician asked Mirlan to do an interview with the reporters. He refused, but still ended up on TV, clearly identified as a person with HIV. While Mirlan wasn’t looking, the doctor had held open some curtains so the reporters could film him without his knowledge.
After the broadcast, Mirlan’s life took a dramatic turn for the worse, deepening the downward spiral that began when he started taking drugs and lost a successful business. People jeered at him on the streets of his small provincial hometown, and refused to serve him in stores. Classmates at school called his children “AIDS carriers.” Mirlan, despite his rapidly declining health, filed a case in court, helped by a UNDP-supported legal aid clinic.
He would not live to see the end, but he would leave a legacy: a landmark judgment against the doctor. For the first time in Kyrgyzstan, a court legally upheld the human rights of a person living with HIV. This was possible because the Government, advised by UNDP, had adopted a new national AIDS Law to protect people like Mirlan.
Putting the pieces together
A small country with a limited economic base, Kyrgyzstan has faced a challenging transition from the days of Soviet dependence. Budgetary resources have been short, and health care spending has declined sharply, even as a new threat from HIV has emerged.
Kyrgyzstan still has a relatively low prevalence of HIV, but the virus is spreading at one of the fastest rates in the world. The country’s location, at the crossroads of drug trafficking through Central Asia, has helped drive the number of injecting drug users up by 50 times in the last two decades, for a current total of around 25,000. Mostly men, they account for about two-thirds of HIV cases. Recent increases in the number of women and children with HIV indicate the epidemic is slowly but surely spreading into the general population.
Stopping HIV requires coordinated actions on many levels: new laws and state programmes, prevention and care services, resources, partnerships and changes in behaviour. Kyrgyzstan started with few of these pieces in place. But with assistance from international partners such as UNDP, it has begun to draw them together.
Protection under the law
Early HIV initiatives focused on directly reaching communities most vulnerable to infection—especially injecting drug users. In 2000, UNDP helped Kyrgyzstan become one of the first countries in Central Asia to pilot needle and syringe exchange programmes. In 2002, it became the first country in the Commonwealth of Independent
States to offer methadone substitution treatment to heroin and opium addicts.
Important momentum came in 2005 from a new national AIDS Law. It grants people with HIV priority access to primary care facilities and medication, and stipulates punishments for cases of stigma and discrimination against people living with HIV and AIDS. For the first time, informed written consent is required for HIV testing, except in cases mandated by court order.
Subsequent policies and regulations bolstered the new law. The Criminal and Administrative Code partially decriminalized some activities involving drugs without an intention to sell, such as the collection of needles at syringe exchanges. In 2007, a new regulation encouraged referrals of drug addicts to syringe exchange and methadone therapy programmes, rather than simply carting them off to jail. This measure has helped reduce the overall number of prisoners by almost half, from 17,000 in 2007 to 9,500 in 2009.
To support these changes, UNDP has helped government officials develop training on HIV for law enforcement agencies. An order from the Ministry of Internal Affairs now requires all police officers working with high-risk populations to learn about issues such as the vital importance of needle exchange programmes in protecting key populations at higher risk, and the rights of people with HIV under the Constitution and other laws.
The difference can be seen on the streets. Police officers who once harassed and arrested injecting drug users now send them to programmes that can save their lives.
Improving plans and services
A year after enacting the AIDS Law, the Government adopted a comprehensive national AIDS programme conforming with the latest international standards in health, justice, law enforcement, education, social protection and information. It prioritized key populations at higher risk, such as injecting drug users and prisoners.
The programme has subsequently helped ensure that HIV support services now reach 60 percent of injecting drug users. By 2011, the Ministry of Health was operating 30 methadone treatment centres. Three additional programmes were running in prisons. In Bishkek, which has had some of the longest-running needle exchange and methadone treatment services, HIV infection rates among users are half the national average.
Consultations on testing have been introduced in healthcare organizations across Kyrgyzstan, and public advocacy has conveyed the message on billboards, radio and television that testing is an important routine medical procedure. Around 350,000 people now undergo it each year.
The national programme has strongly emphasized civil society participation. Under the protections of the AIDS Law, more groups of people living with HIV have formed, and civil society leaders, for the first time in Central Asia, have publicly emerged from marginalized communities, including former injecting drug users, sex workers and men who have sex with men.
Other essential civil society contributions have come from religious leaders. Since Kyrgyzstan is a majority Muslim country, UNDP has engaged the Spiritual Administration of Muslims of Kyrgyzstan and the State Commission on Religious Affairs to train imams to help break through the silence, fear and lack of knowledge associated with HIV. In worship services and other religious activities, they preach about healthy lifestyles and the need to respect one another, regardless of HIV status.
“Everything I do in order to stop HIV is done in the name of God. I am helping people to avoid misfortune and sorrow,” says Maksutov Jusupjanajy, the Chief Imam-Hatib of the Alai District in Osh Province.
Aiming for universal access
Kyrgyzstan today has a foundation in place for stopping the spread of HIV. But it faces formidable barriers to its next challenge: rapidly expanding the coverage and quality of HIV care and prevention services so that everyone has access to them.
The obstacles include ongoing political and economic instability, and the cross-border flow of narcotics, which continues unabated. The fact that HIV infections appear increasingly in small rural communities with limited medical care may prove to be an extra burden on an already overstretched healthcare system. Kyrgyzstan pays a high cost for life-saving anti-retroviral medications and is heavily dependent on declining external financing for HIV programmes.
Hope comes from the growing cadre of officials and civil society advocates who have gained experience in working on HIV programmes sponsored by UNDP and other international partners. A strong legal framework is in place to scale up services—the AIDS Law calls for all people living with HIV to receive qualified medical assistance and free medicine. The latest National Programme, being drafted in 2011, aims for a full menu of protection and prevention services in all healthcare locations, and its targets include ensuring that over 80 percent of children and adults with AIDS can receive antiretroviral treatment, up from the current 23 percent.
In 2011, the Global Fund for AIDS, Tuberculosis and Malaria agreed to continue supporting Kyrgyzstan’s efforts to stop the spread of HIV, offering $31 million towards the goal of universal access to services for people living with the virus. The goal will require more than that sum, but it is an important advance in the right direction for a country striving to stop a terrible disease.