Lauren: Set the stage: How has the HIV epidemic spread in Central Asia? Which populations are most affected & why do you think that’s the case?
David: The HIV epidemics in Central Asia have largely been among injection drug users (IDU), so about 70% of all HIV infections in the region are among IDUs. The next largest group who are HIV infected are female sex workers. There is also a high rate of HIV infections among prisoners, largely due to injection drug use in prison. Men who have sex with men (MSM) are also increasingly being infected in some parts of Central Asia, and there have been a number of outbreaks among children in hospitals throughout the region where appropriate infection control is not being practiced, and there are often unnecessary procedures performed that put children at great risk.
Injection drug use in Central Asia increased dramatically after the fall of the Soviet Union, which led to economic crisis in the region. At the same time, drug trafficking out of Afghanistan through Central Asia to Eastern Europe increased dramatically. Needle and syringe sharing practices among increasing numbers of IDUs put that population at greater risk and resulted in the higher infection rates we see today.
Overall in Central Asia, there are concentrated HIV epidemics among these most-at-risk populations (MARP) and still very low rates of infection among the general population.
Lauren: Prior to the CAPACITY & TUMAR projects, what was the response—in terms of the type & scope of interventions available, as well as community & government support—specifically for IDUs?
David: There had been a number of organizations, including government, that have been working with MARPs for a while, even before USAID funded JSI and our sub-contractors to implement CAPACITY and before the Central Asia AIDS Control Project funded JSI and our sub-grantees to implement TUMAR. To varying degrees, the governments of each country had developed Trust Points where IDUs could exchange needles and syringes. Some of these were funded by the Global Fund for AIDS, TB, and Malaria (GFATM). USAID had funded a drug demand reduction project that focused on reducing injection and other drug use. That also included some HIV prevention, but it was not the central focus of that project. And there were and are others.
The main difference between what we did compared to what was out there already, was to offer comprehensive services, to focus on quality of those services, and to emphasize with implementers the need to achieve high coverage among our target populations. Rather than offering only needle exchange or only HIV prevention education, for example, we offered a range of services including education, counseling, provision of condoms, provision of needles and syringes, referrals to needed medical services, skills training, social support, and reduction of stigma and discrimination. In addition, we put a lot of emphasis on rallying and training important community leaders and members to support our efforts in order to reduce resistance from police and others, which is common throughout Central Asia and elsewhere.
Our objective was to achieve a coverage rate of 60% or more of our target population. We implemented the project in 5 sites around Central Asia targeting IDUs and in 2 sites targeting sex workers. Overall, we reached more than 80% of our target population with at least one contact. But we recognized that to have an impact on reducing HIV transmission, we need to reach our clients with multiple contacts. We set our objective to reach each client with at least 5 contacts before we considered that client covered; and we covered more than one third of sex workers and about half of the IDUs in our project sites. We didn’t meet our 60% coverage target. Nevertheless, from our end-line case-control survey, we know that the sex workers and IDUs in our project areas were much less likely to engage in HIV risk behaviors, such as having sex without condoms and sharing needles and syringes than those who were in non-project areas.
So we think what we did was important and we hope that others working with IDUs will learn from this experience and adopt some of our methodologies.
Lauren: What is important to consider when designing interventions & programs for the most at-risk populations in Central Asia?
David: It is important to strive for high coverage of MARPs with quality, comprehensive HIV prevention services in order to achieve significant behavior change that can reduce HIV transmission. And it is important to complement these efforts with work with the larger community to sensitize it to the needs for these activities and to reduce stigma and discrimination against MARPs and people living with HIV (PLHIV). Going beyond what we actually achieved in our 7 sites, it is important to scale these activities up so that more MARPs have access to these efforts. That of course means more funding is necessary along with political and social commitment from governments to implement such programs on a wide scale.
Lauren: What were CAPACITY & TUMAR’s goals? What were the biggest initial hurdles?
CAPACITY was a very broad HIV and AIDS program. Overall, we wanted to reduce or slow HIV transmission and help improve the survival and quality of life of PLHIV. CAPACITY worked on HIV prevention, care and support, and treatment, and on building capacity of local non-governmental and governmental organizations. We worked hard to help the national AIDS coordinating mechanisms to develop tools to help them manage and coordinate all the efforts responding to HIV in their countries. And we began working toward integrating some HIV prevention and treatment services with the primary health care system.
TUMAR was very focused on providing comprehensive HIV prevention services to IDUs and sex workers to change risky sexual and drug using practices and reduce HIV transmission.
TUMAR and CAPACITY worked together in the area of HIV prevention among MARPs. TUMAR provided the direct funding to local organizations to implement the activities while CAPACITY provided much of the technical assistance to the implementers to improve capacity and quality of implementation. It was a great model of leveraging the funds of one project for another to enable us to do more. And it was a great model of cost sharing between the two projects.
Even so, the biggest hurdle was funding because while we finally did get the additional funding to implement TUMAR, it took three years of CAPACITY to do so. The need for more funding is also evident because of the difficulty to sustain the activities and scale them up after the project finished. Ultimately, to have the kind of impact that is necessary to turn the epidemics around, more funding and commitment is necessary to keep activities going and scale up what we began. It is not clear that either is available with enough abundance.
Lauren: One of your abstracts here in Vienna addresses how high coverage of IDUs with comprehensive services can reduce HIV risk. It sounds so clear, yet so difficult to accomplish – can you talk about the specifics?
David: You are right, it is both clear and difficult. It is difficult because first you need funding and political will. IDUs and sex workers are rarely considered priority populations from the point of view of governments, but in concentrated HIV epidemics such as there are in Central Asia, these are exactly the populations that need to be prioritized.
Next, the populations themselves are difficult to reach. Because of stigma and discrimination, as well as the criminalization of sex work and drug use, people who engage in these activities are hidden. To reach them, we have to draw them out to drop-in centers that attract them with needed services, or find them with outreach workers who know and understand the population.
Lauren: Why do you think CAPACITY was successful? TUMAR?
David: Without a doubt it was the people; we had a tremendous staff working for CAPACITY and TUMAR – hard-working, dedicated staff and a great team. The same was true for our TUMAR sub-grantees. Without a doubt, it is because they wanted to make a difference that we were successful.
Lauren: Now that these projects have ended, what are the remaining challenges in continuing to provide comprehensive services to IDUs?
David: First, we need funding and political commitment. The Office of the Global AIDS Coordinator (OGAC) and PEPFAR just released new guidelines for IDUs; this will significantly change how HIV prevention is done in the region. There is a need to continue building capacity among HIV prevention activity implementers. Through CAPACITY and TUMAR, we have shown that it is possible to achieve high coverage and significantly change behaviors among IDUs and sex workers. Now we need others to pick up the challenge and scale up efforts to replicate these efforts throughout Central Asia.