Operational Plan Report




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Russia
Operational Plan Report
FY 2010

Operating Unit Overview

OU Executive Summary
Several significant events have taken place this year that underscore the need for continued US government (USG) engagement in the fight against HIV/AIDS in Russia. The July 2009 Presidential visit created important momentum in bilateral collaboration on health. This year’s HIV Country Operational Plan (COP) for USG in Russia builds on that momentum and the Memorandum of Understanding (MOU) on health signed at the time of that visit. The MOU is a key step forward in cementing the willingness of the Government of Russia (GOR) to work collaboratively with the USG, and the MOU includes collaboration in the areas of HIV/AIDS and infectious diseases as a key component. The Bilateral Presidential Commission that was announced at the conclusion of the visit, established a Health Working Group that will provide an important venue to highlight progress and identify priorities for the US and Russia. A Counternarcotics Working Group was also established; this Working Group provides another potential venue to address the HIV epidemic in Russia, which is driven primarily by the injecting drug user population.
USG/Russia’s COP for FY 2010 reflects the USG commitment to deepening collaboration with the GOR at the federal level to define and disseminate effective approaches of prevention and care through the GOR’s National Priority Project. It acknowledges the vast resources, both financial and human, in Russia, and the steady and significant commitment to HIV/AIDS by the GOR, and emphasizes that with modest USG funding, the USG is well positioned to help ensure that GOR resources are used effectively to target gaps in life saving prevention and care among injecting drug users (IDUs) and their sexual partners.
The time is right to bolster targeted efforts to address HIV/AIDS prevention and care for most-at-risk groups (MARPs), particularly IDUs, in light of recent epidemiological data indicating that a second wave of HIV transmission among IDUs is underway in several regions of Russia. While the GOR has been receptive to USG and other external partners’ advocacy for more concentrated emphasis on the IDU population, given the stigma associated with drug use and HIV, the GOR itself needs the support of international partners to help articulate the way forward. This is particularly important as the first of the Global Fund (GF) grants, GLOBUS (Round 3), the major prevention project closed in August of this year and it is the GOR that has indicated it will continue to support these prevention efforts. However, the level of funding for HIV/AIDS prevention, although having increased in the past years, continues to be the least well funded. Prevention activities, especially for MARPs and IDUs remain the most difficult component for the GOR to address; resulting in significant gaps in halting the spread of HIV/AIDS. USG support is targeted at addressing these issues.
The COP reflects the continued strategic shift towards greater work with the Federal level as the USG HIV/AIDS program gradually phases down. With $6 million in FY2010, the USG program will advance work started in FY09 to facilitate greater GOR emphasis on addressing HIV/AIDS prevention and care for IDUs. The FY 2010 COP includes funding for four main implementing partners, down from 10 partners last year, demonstrating a more concentrated approach for the USG program. The program targets improving the enabling policy environment for prevention and care for IDUs, engendering sustained support for such programs. The USG program will also dedicate FY 2010 resources to the most under-developed component of HIV prevention among MARPs in Russia – substance abuse treatment options for injecting and non-injecting drug users. FY 2010 activities in this area will build on the pioneering work of USG partners in FY 2009 to integrate HIV prevention into substance abuse (narcology) services in Russia and expand the spectrum of substance abuse treatment options available for IDUs and other MARPs.
Update on HIV Epidemic in Russia: Second Wave of IDU Transmission is Underway

The HIV/AIDS epidemic in Russia continues to evolve, with recent data suggesting a second wave of injecting drug user transmission is underway in specific regions. The GOR estimates there are 750,000 people living with HIV/AIDS (PLWHA) in 2009; the change from the 940,000 PLWHA estimated in 2007 is due to improved estimates rather than a change in the epidemic. Although HIV incidence has markedly decreased since 2001 due primarily to a decline in injecting drug use transmission, a second wave of transmission among IDUs has emerged in key regions. Available GOR data indicate that new outbreaks of HIV among IDUs began in two Siberian regions on the border of Kazakhstan in 2007 (Novosibirsk and Altay) and spread within three adjoining regions (Kemerova, Omsk and Krasnoyarsk) in 2008. The increase in newly detected cases in these five regions accounts for half of the increase nationwide since 2006.


In 2008, the number of newly detected cases reported nationally increased by 36% over 2006 (54,046 cases in 2008 compared to 39,652 cases in 2006). The five Siberian regions reported a 280% increase in detected cases while the remainder of the country had a 20% increase in detected cases. While smaller in scale than the national epidemic wave of the late 1990s, the recent upsurge in Siberia represents significantly increased transmission among IDUs. The factors accounting for these new outbreaks have not been investigated to date, and important stakeholders have not yet appreciated that these increases likely represent a spreading outbreak. While the fact that this second wave has been identified using GOR’s routine HIV case reporting is positive, this still reflects persistent incomplete analysis and use of data gathered through the routine HIV case reporting system to channel resources towards MARP prevention. Using FY09 funds, efforts to conduct and institutionalize surveillance activities using second generation surveillance techniques will continue in FY10 with technical support from the USG and other international partners.
IDUs continue to account for about two-thirds of newly-registered cases (63% in 2008). Outside of the regions with new outbreaks, IDU transmission appears to have declined after 2001; due to a combination of prevention programs, declines in IDU initiation, diffusion of prevention knowledge among IDU, wide availability of syringes in pharmacies. However, injecting drug use continues and safe injection practices are incompletely practiced, especially regarding sharing of injecting equipment other than needles and syringes. The surveillance data suggests the biggest unmet prevention needs remain among IDU and their sexual partners.
Heterosexual transmission continued to increase this past year but available data, while limited, suggest this remains likely to be largely concentrated among direct sexual partners of IDUs. The available data show an increased percentage of female cases overall (42%) and an increased number of female HIV cases who report only sexual risk factors. Despite an increase in female cases, the evidence suggests that personal injecting drug use still accounts for a significant proportion of newly detected cases while direct sexual contact with IDUs is the other major risk.
The prevention of mother-to-child transmission (PMTCT) has been a significant success in Russia although residual gaps remain. Nationally, in 2008, 14,364 pregnant women (0.49% of all pregnancies) were HIV-positive and 8,925 HIV-exposed children were born. During pregnancy, 82% of HIV-infected pregnant women received antiretroviral prophylaxis and 92% of HIV-infected pregnant women and 98% of exposed infants received prophylaxis during delivery. In 2008, 723 HIV-infected children were identified. Since 1987, 3,425 (9.6%) of 35,700 HIV-exposed children with complete follow-up have been confirmed as HIV infected. Enhanced surveillance in St. Petersburg shows that implementation of prophylaxis prior to delivery remains significantly lower and transmission to infants significantly higher among the 40% of HIV-positive pregnant women with a history of IDU.
The face of the Russian epidemic is aging and now, as noted above, includes many females. While male IDUs in their early twenties are still affected, newly-detected cases in recent years also increasingly include male IDUs in their late twenties or early thirties and women in their mid-twenties infected by either injecting drug use or sexual contact. Over 82% of all cases detected before 2004 were detected at under 30 years of age -- only 53% of all newly detected cases (and only 48% of male cases) in 2008 were under 30. This increase in age among newly detected cases likely reflects both continued detection each year of some of the large cohort infected in the peak incidence years as well as current transmission among individuals of older age. Continued transmission, even at current estimates poses significant future burdens in terms of health care and demographic impact.
GOR Commitment to HIV/AIDS, Including Support for NGOs

To respond to the expanding HIV epidemic in Russia, the GOR has demonstrated a growing commitment to support a holistic response to HIV/AIDS over the past few years, through increased government resources for HIV prevention, treatment and care to meet Universal Access goals and targets. Since the establishment of the National Government Commission on HIV in 2006, the GOR has continually increased funding for HIV programs through the National Priority Project, with a 2009 budget of $400 million. The GOR has identified prevention among MARPs as one of its priorities; however, funding for prevention represents less than five percent of the total GOR spending on HIV and only 25% of this figure was targeted directly for MARPs. Although there continues to be sensitivity at the federal level around medication-assisted treatment (MAT) and specifically methadone, there has been important dialogue on a broad package of services for IDUs referred to has harm reduction in FY 2009, including a recent meeting of the State Duma on harm reduction which established working groups to evaluate the effectiveness of harm reduction in the Russian context.


The GOR has also acknowledged the complementary role that civil society organizations play in reaching MARPs with HIV prevention, treatment and care, awarding a number of federally-funded grants to the burgeoning number of NGOs active in this area. In recent years there has been an increase in the number of NGOs working in HIV prevention among MARPs. According to UNAIDS data, more than 200 NGOs are working in HIV. Representatives of NGOs sit on a number of GOR senior level commissions, including the GOR HIV Commission and the GF Country Coordinating Mechanism (CCM).
USG/Russia Program Prioritizes FY 2010 Funds to Prevention and Care for IDUs

The GOR, while making strides in treatment and care programs, reaching its own goals of over 55,000 HIV+ individuals on antiretroviral treatment in 2009, continues to have a major gap in addressing MARPs. The USG Russia program targets FY2010 funding more directly on HIV prevention and care for IDUs this year, and on improving the enabling policy environment for these areas. In order to better understand how to best target limited USG funding to help improve HIV prevention and care in Russia, USAID/Russia arranged for an assessment of the sector in February/March 2009. Highlights from the assessment include the following:




  • USG-supported bilateral programs offer solid models of prevention and care for most at-risk populations, some of which may be considered for broader dissemination throughout Russia beyond the two PEPFAR focus regions, in collaboration with the federal government.

  • Effective prevention programs in Russia should include emphasis on prevention activities among MARPs in order to adequately address the epidemic.

  • Prevention activities including peer and street outreach programs; case management training, HIV and substance abuse, including issues of drug dependency and effective treatment such as MAT; support groups for PLWHA, MARPs, and their families; and, drop-in centers are key interventions for an effective prevention program addressing a concentrated, IDU-driven epidemic.

  • Effective dissemination of key HIV policy needs coordination among key stakeholders and related ministries.

  • A systematic approach to assess the models and determine success and adaptability of models for disseminated on a broader scale is warranted.

The COP outlines a plan to promote stronger GOR emphasis on prevention and care programs for IDUs through a focused effort to garner Federal-level endorsement of HIV prevention and care packages for IDU that can be widely disseminated through the National Priority Project and adopted in the regions. To accomplish this, modest yet sufficient funding in the next 4-5 years is essential. Post proposes to establish a Partnership Framework for the next five years ($6 million in FY 2011 and $4 million in FY 2012/2013/2014) which will help the USG Russia Program engage with the GOR to provide targeted technical assistance to help the Russians develop and implement their programs in the future. Continued USG leadership and collaboration with the GOR is especially important as the support for prevention and care programs for IDUs through the Global Fund phase down. While the GOR has recognized the importance of working with MARPs, the transition and ownership of such programs remains a challenge. USG assistance will help foster this process, facilitating the appropriate pathway for this transition and a sustainable approach.


a) USG/Russia -- HIV Prevention among Most At-Risk Populations

The USG Russia team proposes to concentrate FY 2010 resources to address prevention among IDU and their sex partners, allocating over half of the FY 2010 budget for this area. This focus is consistent with data indicating a continued concentration of the HIV epidemic in Russia among this risk group.


The recent high-level Presidential dialogue between the USG and the GOR provides an important framework for the USG Russia Program to engage with the GOR to jointly define an essential, minimum package of HIV prevention for IDUs. Key GOR counterparts – including Rospotrebnadzor – the agency responsible for the GOR’s main HIV program, the National Priority Project (NPP) – have confirmed their interest in continuing collaboration with the USG and have already moved ahead with the USG to jointly manage the new USG prevention approach. Such a package will likely incorporate a range of interventions, including peer outreach services and case management for HIV prevention that have been previously piloted with USG support, as well as needle exchange, which is funded by local governments in many regions of Russia and is currently supported by the Global Fund Round 5 Harm Reduction Project. In addition, HIV prevention among sex partners of IDUs will be targeted through both gender-based and family-targeted integrated drug prevention and treatment programs. These approaches will also address the weakest component of HIV prevention among IDUs in Russia – substance abuse services (narcology services), building on the nascent success of USG partners to integrate HIV prevention into substance abuse treatment services and to expand the spectrum of drug treatment services and HIV prevention available to IDUs, their sexual partners and other drug users. Although methadone is still illegal in Russia, the USG Russia Program will continue to engage in policy dialogue with GOR counterparts on international best practices for medication-assisted treatment (MAT), including with buprenorphine, naltrexone and methadone. Given the continued sensitivity of MAT in Russia, an incremental approach is essential to engage with the GOR on these issues. As a starting point for MAT, the USG Russia Program is exploring support for a study on MAT using naltrexone, using wrap-around funds.
b) USG/Russia --HIV/AIDS Care and Support

The maturation of Russia’s epidemic means that a large number of HIV-positive individuals infected in the early days of the epidemic starting in 1989 are now reaching advanced stages of immunodeficiency and are in need not only of ARV treatment but overarching primary care, as well as sub-specialty care to address the other co-morbidities observed in HIV-positive IDUs. To improve the access of IDU and other MARPs to HIV/AIDS primary care, the USG Russia Program will use FY 2010 funds to engage with Rospotrebnadzor to replicate the model of decentralized care for people living with HIV/AIDS (PLWHA), successfully piloted with USG support in the PEPFAR target regions. Decentralizing HIV/AIDS care and treatment from AIDS Centers to primary care clinics has helped the PEPFAR focus regions of St. Petersburg and Orenburg achieve important successes in increasing the number of PLWHA – most of whom are IDUs – in care and treatment. Engaging with the federal government agency responsible for the GOR’s HIV/AIDS program – Rospotrebnadzor – to endorse this model so that it can then be used as a basis for regional strategies on HIV/AIDS care will help ensure the sustainability of the USG Russia Program’s investments to date in this area.


c) USG/Russia -- Health Systems Strengthening and Strategic Information

Within the two priority areas of prevention and care among IDUs, the USG/Russia Program will continue to strengthen the health systems so that government partners can disseminate effective approaches developed with USG support and to institutionalize services to address the epidemic in the long term. With FY 2010 funds, UN partners will promote strategic planning and management through Universal Access processes and the adoption of the “Three Ones” (specifically one national coordinating authority, one national plan, and one national monitoring and evaluation system). FY 2010 funds will support UNODC to continue the dialogue with government officials on substance abuse treatment, including the integration of HIV prevention into substance abuse treatment, expanding the spectrum of drug treatment services, and MAT.


USG assistance for improved strategic information to better guide prevention and treatment efforts will focus on the completion of enhanced surveillance activities among key risk and bridge groups in target regions, workshops to integrate these data with data from routine surveillance and other sources, and continued work with federal authorities to incorporate these activities into national guidelines and programs.
A US–Russian HIV/AIDS Partnership Framework

The renewed momentum in the wake of the July 2009 Presidential visit to deepen collaboration with the GOR provides a strong platform for the USG/Russia program to develop a Partnership Framework (PF) with the GOR with modest funding. With vast GOR financial and human resources, Russia is an ideal candidate. The GOR can and must do more to effectively curb the HIV epidemic. By continuing to invest modest amounts of USG resources, the USG may catalyze further increases in Russian funding and help ensure that this enormous financial contribution is used effectively. A modest yet effective PF is envisioned to enable the USG to remain engaged in the dialogue promoting the continued emphasis on IDUs and potentially allowing for significant emphasis on the most difficult challenges such as drug dependency. Within the context of the HIV prevention and care approaches underway in FY09 and FY10, the PF would allow for more targeted work on this difficult aspect of the epidemic and would facilitate the use of accepted international approaches to HIV/AIDS in Russia’s fight against HIV/AIDS.



Population and HIV Statistics

Population and HIV Statistics




Additional Sources

Value

Year

Source

Value

Year

Source

Adults 15+ living with HIV



















Adults 15-49 HIV Prevalence Rate



















Children 0-14 living with HIV



















Deaths due to HIV/AIDS



















Estimated new HIV infections among adults



















Estimated new HIV infections among adults and children



















Estimated number of pregnant women in the last 12 months



















Estimated number of pregnant women living with HIV needing ART for PMTCT



















Number of people living with HIV/AIDS



















Orphans 0-17 due to HIV/AIDS



















The estimated number of adults and children with advanced HIV infection (in need of ART)



















Women 15+ living with HIV




















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