Using Data For Decision Making Juliana Víctor-Ahuchogu World Bank
Acknowledgment and data sources AIDS in the Commonwealth of Independent States: AIDS 2008 MAP Report: Magomed Nashkhoev & Boris Sergeyev, accessible at: www.unaids.ru Andrew Wilson, Liza Shurik, Anja Nitzsche- Bell & Igor Toskin MAP 2008 Report primary data collection teams: Azerbaijan, Tajikistan, Belarus, Georgia, Turkmenistan, Kazakhstan, Ukraine, Kyrgyzstan, Moldova, Uzbekistan 2
Critical Questions in Decision- Making Are we doing the right thing? Are we doing it right? Are we doing enough of it? 3
What have we always known about the HIV epidemic in the region? Injecting drug use remains the driving force behind the HIV epidemic in the region 4
RESPONDING TO CONCENTRATED IDU EPIDEMICS Throughout Asia and Eastern Europe, IDU drives HIV, directly and by injecting HIV into commercial sex networks Injecting drug use the spark plug that ignites sexual transmission, sex work the engine that maintains it European and Asian data shows how injecting drug use fuels HIV in sex work, fundamentally amplifying epidemic potential Eastern Europe, Central Asia, Iran, Afghanistan, Pakistan, Indonesia, Philippines lands of opportunity - effective IDU programs can radically curtail sexual epidemics 5
RESPONDING TO CONCENTRATED IDU EPIDEMICS Yet real world experience discouraging Can we keep saying that harm reduction works, for example, in former Soviet Union or Asia, when we can t convince authorities it is preferable to coercion? Limited progress towards large-scale harm reduction programs in Asia, with partial exception of substitution therapy in China Yet, if we can increase programs, we have inherent advantages - unlike condoms, which inhibit spontaneity, no-one WANTS to share dirty needles 6
HIV Prevalence among IDUs in Nine CIS states 2003 2006 (2006 UNGASS Reports) 25 23.2 20 15 10 12.4 5 10.9 5 6.2 9.2 13 5 1 0 Russia Ukraine Belarus Moldova Kazakhstan Kyrgyzstan Armenia Georgia Azerbaijan
Coverage of prevention services among IDUs still low in most countries In most CIS countries, police are known to arrest IDUs for possession of even minimal amount of narcotics. As a result of the fear of incarceration or of being registered as a drug user, many IDUs do not seek treatment or even clean needles!!! How can we match evidence and programmatic decision-making? 8
Percentage of IDUs reached by prevention programs, 2005 source: 2006 UNGASS Reports 70 69.3 63.3 60 50 % 40 30 25.1 25 30 22.3 28.9 20 16.4 10 0 4.9 Arm Geo Rus Ukr Bel Kyr Taj Mol Arm 9
Behavior change still a challenge among IDUs High levels of needle- and syringe sharing: Russia: 30-40%, Tajikistan: 55%, Kyrgyzstan: 70% (prisons Patterns of adopting protective behaviors differ significantly throughout the region: Moldova: 60%, 20% or less in Georgia, Ukraine and Kyrgyzstan Even higher levels of sharing injecting paraphernalia (containers, filters) and water to prepare drug solution 10
IDU Equipment-Sharing Practices Source: MAP Report, 2007 % of IDUs 60 50 40 30 20 10 Sharing Needles Sharing instruments 0 Tajikistan Kazakhstan Kyrgyzstan Ukraine Moldova 11
Sexual Behavior of IDUs Drug users are sexually active - 86% St. Petersburg > 80% Ekaterinburg Multiple sex partnerships common Concurrent sex partnerships common Armenia, 63% more than one partner in last 12 months 54% two or more partners concurrently 12
Female sex workers Sex industry experienced a dramatic growth after the collapse of the Soviet Union Most are between 20 and 25 years of age, however a significant proportion of sex workers are under the age of 18 Many women travel outside the region for sex work and outside their country within the region. 13
HIV prevalence among female sex workers Ukraine: prevalence varied for 4% in Kiev to 24% in Donetsk and 27% in Mikolayev Russia: prevalence ranged from 15% in Moscow to 48% in St Petersburg and 62% in Togliatti. High overlap between sex work and injecting drug use communities in most of the region. 14
HIV Prevalence among sex workers in eight CIS countries Source: 2006 UNGASS Reports Armenia 0,4% Georgia 1,2% Kyrgyzstan 0,1% Kazakhstan 2,5% Moldova 8,4% Russia 3,1% Tajikistan 0,7% Ukraine 8,0% 0,0% 1,0% 2,0% 3,0% 4,0% 5,0% 6,0% 7,0% 8,0% 9,0% 15
Condom Use during commercial sex is high. Source CDC, (HIV SS, 2005, Kazakhstan, Kyrgyzstan, Uzbekistan) 100% 91% 90% 87% 80% 72% 70% 61% 60% 50% 40% 30% 20% 10% 48% 83% 0% Kazakhstan (N=1960) Kyrgyzstan (N=349) Uzbekistan (N=315) Have condoms at the moment of interview Used condoms during the last commercial sexual intercourse
CIS epidemics remain focused in specific populations & their partners Clients Low or no risk males FSW Low or no risk females IDUs Limited generalized spread Focused prevention effective Intensified efforts among bridging populations needed Adapted responses needed as epidemic changes (adapted from Brown & Walker 2005)
But coverage (prevention) among female sex workers is low. 80.0% 75.7% 75.3% 70.0% 60.0% 62.3% 50.0% 40.0% 30.0% 28.9% 34.0% 20.0% 10.0% 8.8% 14.1% 16.0% 0.0% Armenia Belorussia Georgia Kyrgyzstan Moldova Russia Tajikistan Ukraine (2006 UNGASS Reports, NAC data) 18
Injecting drug users selling sex Russia: 15%-50% of female IDU sell sex and 30% of sex workers inject drugs Injecting sex workers more frequently nonsterile injecting equipment Female injectors more likely to share needles or syringes than male injectors 19
Shooting up: Epidemics in IDU are injecting HIV into heterosexual groups The Main Routes of HIV Transmission in Russia, 2001-2006 % 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 Injecting drug use Heterosexual sex (Data source Russia, Ukraine, Belarus : MAP Report 2007) 20
Distribution of HIV infection by Transmission Routes, Ukraine:2001-2005 # of newly reported cases 7000 6000 5000 4000 3000 2000 1000 0 6270 5778 4587 4815 4586 3964 4041 3043 2499 1885 2001 2002 2003 2004 2005 IDUs Heterosexual Transmission HIV infection by Transmission Routes, Belarus: 2001-2005 100% 50% 0% 2001 2002 2003 2004 2005 Heterosexual Transmission IDU Mother to Child Transmission Diagnosed in MSM
Case Study, Using Data to improve Resource allocation, Russia In 2004: Low spending: Only 0.2% of the total Russian health budget was allocated to HIV/AIDS treatment and prevention in 2004. Imbalance in spending for prevention activities: close to 50% spent on blood safety, one-fifth of the funds aimed at mother-to-child transmission and 30% was spent on mass media activities (almost zero spending on MARPs). 22
NASA Study Results, Russian Federation, 2004 Allocations by functions, source UNAIDS Russia 23
Allocation to Prevention Activities, Russian Federation, 2004, source UNAIDS Russia 24
Russia: Improvements in funding allocation Based on the findings of the NASA study, in 2006-2007, the Russian government increased funding for HIV/AIDS In 2006 the government allocated 18 times more funding than in 2005 In 2007, the federal budget allocations for HIV/AIDS was three times higher than in 2006 In 2006, 20.30% of the total allocation for HIV/AIDS was used for prevention (source, Russian Federation UNGASS Report, Jan 2006- Dec 2007) 25
MSM Remains the least-researched of the most-at-risk groups in CIS Available data on prevalence and risk behaviours is limited Most data collected from venues such as gay nightclubs young adults <30 No data from Azerbaijan, Tajikistan, Turkmenistan, the Ukraine and Uzbekistan Russia, 4.8% in Ekaterinburg and 14.3% in Volgograd; Georgia: 3.2%; Moldova: 2.5% 26
Migration, mobility and HIV Significant role in the epidemic? HIV prevalence data missing Data on risk behaviour patterns missing Caucasian Republics: Azerbaijan data suggests 45% of HIV positive population infected abroad Central Asia: Tajikistan reports >50% of HIV cases are among seasonal workers 27
Discussion: Significant challenges What can we learn from Ukraine, Kyrgyzstan and Tajikistan and other countries which report no barriers for IDUs in accessing preventive services? Because despite strong anti-narcotics policies and punitive measures towards IDUs, most of the countries in the CIS have experienced a significant increase in injecting drug use in the last decade. 28
Significant challenges: 2 Govt size estimate reports and other sources do not match, leading to mismatch in resource allocation Sometimes up to 50% of VCT clients do not return for their results. How can we resolve this situation? Geographic targeting within countries, are we doing the right thing? 29
Why is there a mismatch between evidence and response? What are the critical challenges How can these challenges be overcome? 30