On 6-9 February 2017, Alliance for Public Health held a four-day working meeting for partners implementing the project “Harm Reduction for Children and Young People Who Use Drugs in Ukraine” with support of the Elton John AIDS Foundation aimed at comprehensive prevention work with adolescents. Such project is implemented in Ukraine for the first time.
This project is unique because adolescents are an integral part of project team, which includes diverse specialists who are open to implementing new initiatives and demonstrate unbiased attitude to adolescents. As of today, project teams engaged over 5,000 adolescents to prevention efforts.
The working meeting held in the beginning of February 2017 was aimed at sharing the results of project activities in the field and discussing new areas, such as enrolment of adolescents from risk groups, online counseling, project supervision as well as capacity building of staff in partner organizations.
Participants of the meeting discussed successes and challenges in achieving 90-90-90 targets and key barriers in HIV testing and jointly developed ways to overcome such challenges.

One of the important program components is organizing social and medical support for adolescents who use drugs. The participants reviewed scheme of the work of social and medical support teams, criteria of client enrolment into the support program and practical cases, with which local teams face.

“The meeting allowed to once more discuss the issues arising in the course of project implementation, I learned a lot of new and important things concerning first contact with adolescents.”
Anatolii, project coordinator, Our Help NGO (Sloviansk)

“It really helps that our work is structured and we are supported by our partners in solving difficult situations. We like it that we can use the wide range of forms and tools in working with this target group.”
Iryna, psychologist, The Way Home NGO (Odesa)

On 3 February 2017, Alliance for Public Health officially presented the project “Fast-track TB/HIV responses for key populations in EECA cities” supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Ukraine will be represented in this project by Odesa, where the regional project was announced today. The goal of the project is to develop sustainable response to the HIV/TB epidemics in key populations at the level of Odesa, which will significantly contribute to achieving the 90-90-90 targets in key populations. Gennadiy Trukhanov, the mayor of Odesa, assured that he supports the initiative and is ready for future cooperation. It is expected that the project will help to enhance the dynamics towards reducing AIDS and TB mortality in Odesa and ensure sustainable response to the epidemics at the city level.  Launch of the project was announced at the meeting of a wide range of civil society organizations and relevant agencies of the city chaired by the mayor. Andriy Klepikov, executive director of Alliance, expressed his sincere gratitude to the city administration for their commitment to improving the health of Odesa residents. He said, “We hope that such attitude will both set the tone for this regional initiative and will become an example for the mayors of other Ukrainian cities”.

On 26 January 2017, the Ministry of Health of Ukraine hosted the first meeting of the Coordinating Group on Implementing Activities to Reform the Healthcare System in the Area of TB Response. This first session of the Coordinating Group chaired by the Deputy Minister of Health, Oksana Syvak, was attended by partners representing government and civil society as well as representatives of the WHO Regional Office for Europe and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Coordinating Group will include representatives of the Alliance: Sergiy Filippovych, Director: Treatment, Procurement and Supply Management and Yulia Chorna, Project Manager: TB Advocacy.

The group was created in order to elaborate and implement an action plan on the TB care reform in Ukraine. An important aspect of this reform is support of patient-oriented treatment of TB patients using outpatient care models. The specific objectives, which should be resolved by the government in the course of reforming the TB care, are related to capacity building and management of human resources as well as improving the effectiveness of funding in the delivery of TB care. The state, guided by the Ministry of Health, demonstrates its commitment to the reform by supporting the high-level national coordinating group.

The priority in providing support to TB patients is a focus on outpatient services. New funding models will be implemented based on the results of activities in this area. As for the resulting resources, they will be reinvested to support TB response interventions at the outpatient stage. As part of the new model of health care for TB patients, the required mechanisms of social contracting will be developed to supply TB services, in particular in the context of working with key populations.

The national coordinating group was created within the regional TB-REP project (TB in Eastern Europe and Central Asia Project on Strengthening Health Systems for Effective TB and DR-TB Control), with Alliance for Public Health being partner of this Project on behalf of TB Europe Coalition. The project is aimed at reforming the TB care system as part of the general health care reforms and is implemented in 2016-2018 with financial support of the Global Fund in 11 countries of Eastern Europe and Central Asia (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan). Principal Recipient of the Global Fund grant is the Center for Health Policies and Studies (PAS Center), with technical leadership of the WHO Regional Office for Europe.

The general goal of the project is to reduce the TB burden and to halt the spread of drug-resistant TB by ensuring political commitment and extensive use of evidence-based patient-oriented approaches in the delivery of TB prevention, care and treatment services. An important approach of the project is joining efforts at different levels – from the state to the civil society – to provide more effective TB care. TB Europe Coalition together with the Alliance for Public Health is responsible for the component of supporting advocacy efforts from the side of civil society organizations implementing the project in 11 countries. Civil society partner of the Project in Ukraine is CO “The Ukrainians against TB”. The main advocacy efforts of civil society organizations are aimed at supporting the transition to patient-oriented models of TB care with a focus on providing such care in outpatient settings.

Intensive discussions, which have been taking place in the recent week, while negotiating various approaches to the preparation and submission of the next request to the Global Fund for the period of 2018-2020, led to consolidation of the key positions of all three Principal Recipients of the current GF grant.

Key outcomes of the dialogue:

• Agreeing on the option of submitting the new funding request on HIV/TB in a form of full application by 20 May 2017 based on the principles of transparency with full inclusiveness of all communities affected with the epidemics of HIV and tuberculosis and civil society organizations. The main programmatic priorities of the new request should be achievement of the 90-90-90-90 targets.
• Receiving clear guarantees of ensuring state funding to provide treatment and prevention services to key populations. In the new request, the government should demonstrate how it will ensure gradual transition to full state funding of all programs from the national budget till
• Recognizing the role of civil society at all stages, including its role in governance, management and implementation structure of the future program. Taking into account that USD 60 mln (50% of the total funding) will be designated for key populations, the parties agreed on dedicated funding to develop capacity of the communities affected with the epidemics of HIV and tuberculosis.

The joint statement (attached) was signed by the heads of the Alliance for Public Health, Public Health Center of the Ministry of Health of Ukraine and the All-Ukrainian Network of People Living with HIV.

THE JOINT STATEMENT

Currently most effective directly-acting antiviral agent for hepatitis C (HCV) treatment has already arrived to Ukraine! Alliance for Public Health launches the third phase of HCV treatment program for key populations. This phase stipulates using a direct-acting antiviral agent, which is new for Ukraine – Harvoni (sofosbuvir/ledipasvir) – as well as continuing using sofosbuvir-based regimens. Those drugs are highly effective and demonstrate much fewer side effects as compared to the traditional pegylated interferon-based regimens. According to WHO, at least 94% of patients can be cured with such drugs (treatment success rate may be up to 100%) (http://www.who.int/hepatitis/news-events/hepatitis-c-guidelines-2016-story/en/). Both drugs are recommended by WHO for hepatitis C treatment  (Guidelines for the Screening, Care and Treatment of Persons with Chronic Hepatitis C Infection http://apps.who.int/iris/bitstream/10665/205035/1/9789241549615_eng.pdf?ua=1), as well as the national guidelines (Unified Clinical Protocol of Primary, Secondary (Specialized), and Tertiary (Highly Specialized) Medical Aid “Viral Hepatitis C in Adults” ).

Within the third phase of the Program, Alliance plans to provide free access to innovative HCV treatment to 750 patients – members of key populations and military troops taking part in the armed conflict in the east of Ukraine. Drugs for 500 treatment courses, which are already at the warehouse of Alliance, have been donated.

Treatment will be delivered in 21 healthcare facilities (20 state-run institutions and 1 private clinic) in 15 regions of Ukraine. In total, starting from June 2015, treatment was provided in 25 healthcare facilities in 19 regions of Ukraine. Alliance is considering a possibility of further program expansion. For the first time, the list of healthcare institutions will include the Main Military Hospital with a special quota for the military servicemen (20 treatment courses).

In the beginning of February, Alliance will organize training for the medical doctors who will prescribe new regimens in line with the WHO guidelines and the updated national protocol of HCV treatment.

As of 1 January 2017, access to treatment within the Alliance hepatitis C treatment program was provided to 1,207 patients representing key populations, 78% of whom are HIV-positive. Treatment success rate among the patients, who already had their follow-up tests 12 weeks after treatment completion, is 94%.

Alliance also makes all the efforts to ensure inclusion of Harvoni and other essential direct-acting antivirals to the national list of essential medicines to be procured with national and local budget funds. Unfortunately, the draft list published at the website of the Ministry of Health does not contain any of the direct-acting antivirals, which have been procured by Alliance for over two years.

Healthcare facilities to implement the third phase of the program

on the Status of HIV/TB/HCV Prevention and Treatment and OST Programs in Donetsk and Luhansk oblasts
(as of 23 January 2017)

Alliance for Public Health with support of the Global Fund to Fight AIDS, Tuberculosis and Malaria launches a new pilot project “Result-Based Financing (RBF) for DOT Provision to TB Patients at the Ambulatory Phase”. The main aim of this project is to pilot new ambulatory treatment financing models to focus healthcare professionals on the results: bringing down the number of drop-outs and improving treatment success rates. Such approach will surely contribute to a higher transparency in funds utilization and will allow identifying challenges in directly-observed treatment (DOT) of tuberculosis. Involving primary health care institutions is equally important as it will be a good incentive for medical personnel of such institutions.

On 22–23 December 2016, presentation of this project was held in Odesa attended by chief physicians of primary health care centers, district TB treatment doctors and leading specialists of the Odesa regional TB treatment center. The participants discussed the prerequisites of transition to ambulatory TB treatment models, challenges existing in the region and the ways to overcome them.

The project will be implemented in 2017 in 14 districts of Odesa oblast. Districts to implement the pilot project were selected based on the high TB prevalence, the need to considerably improve the existing treatment success rates for patients with sensitive TB and multidrug-resistant TB (hereinafter – MDR-TB) and, at the same time, high commitment of the regional administration to fighting the TB epidemic, implementation of new projects, cooperation with international and non-governmental organizations and readiness of primary health care institutions to take upon the functions of directly-observed treatment of TB patients at the ambulatory phase.

The results of this pilot project may form a solid basis for the general strategy of ensuring sustainability of TB programs, contributing to the achievement of the goals set forth in the Global Plan to End TB.

Within this project, health care institutions will provide directly-observed ambulatory TB treatment within any format of care (DOT offices at TB treatment centers or primary health care institutions, home care, day care, etc.), keeping relevant records.

For the goals of this project, 380 patients with both sensitive and drug-resistant TB will be enrolled in treatment. This pilot project stipulates a new way of financing ambulatory DOT. Implementing partners will receive financing for each ambulatory patient, which will contribute to increasing treatment success rates (treatment completion with such results as “cured” or “treatment completed”) and working with patients to form adherence to treatment (the higher the adherence of a patient, the less funds are to be spent to retain such patient in treatment). If target indicators are met, incentive bonuses will be paid, which health care institutions will be free to spend at their own discretion within certain limits, which will boost their interest in this project.

On 27 December 2016, Alliance for Public Health (Alliance) delivered materials for the prevention of HIV, viral hepatitis and sexually transmitted diseases to the occupied areas of Donetsk and Luhansk oblasts. This delivery will cover the needs of community-based organizations, which continue implementing prevention programs in the occupied areas, for the first six months of 2017. The materials delivered included:

• 20,362 rapid tests for HIV, hepatitis and sexually transmitted infections;
• 1,240,000 condoms and lubricants;
• 5,300,240 sterile syringes and wipes.

In the areas not controlled by the Government of Ukraine, HIV prevention services continue to be provided to at least 20,000 members of key populations. However, program monitoring data show that the level of HIV infections in Donetsk and Luhansk oblasts in almost twice higher than the average rate in Ukraine. During 9 months 2016, within the Alliance-supported prevention programs 31,213 HIV tests were provided in the region, with 1.3% positive results in Donetsk oblast and 1.02% – in Luhansk oblast.

The same way as last year, Alliance ensured the delivery of drugs for multidrug-resistant tuberculosis, which will cover 4 months of treatment for 500 patients (34,440 packs). This is the first in a cycle of the planned deliveries. We expect at least one more delivery to be made to TB treatment facilities located in Donetsk and Luhansk in the nearest future.

Provision of the humanitarian aid was agreed with the Global Fund and the HIV/TB/OST Sub-Cluster.

Despite some initial barriers like challenging visa process and long distance 16 representatives from Kenya Red Cross Society and their partner organisations visited Alliance for Public Health (Alliance) to study experience of addressing HIV and Hepatitis C epidemic among key populations. On 12 December, 2016 our guests from sunny Kenya reached cold and snowy Kyiv and were welcomed by staff of Alliance.

During the visit to Alliance office participants of the site visit learnt about key interventions, implemented by Alliance for Public Health and its partners and recent programme innovations, policy and advocacy work. During 5 days of the visit they had a chance to visit healthcare settings providing integrated services to people who use drugs (PWUD), drop-in centres, secondary exchange site, learnt about the work of mobile ambulance observing services provided to sex workers, visited community centre for men who have sex with men.

Alliance for Public Health has long-term collaboration with Kenya colleagues bringing harm reduction to Kenya and building capacity of local experts. As a result, needle and syringe exchange was launched and extended in the country under Community Action on Harm Reduction project www.cahrproject.org supported by the Dutch government and run by International HIV/AIDS Alliance together with their partner Kenya AIDS NGOs Consortium.

As a result of the visit representatives from Kenya delegation already started discussing the possibility of piloting new innovative approaches they saw in Ukraine in their home country. Some interventions like pharmacy-based intervention, peer driven intervention, using SyrEx cloud in HIV prevention programmes can be adapted taking into consideration Kenya context and piloted in the country.

Cosmus Maina from Teens Watch reflected on his experience: “I visited the needle and syringe exchange programme, opioid substitution therapy and sex workers programme. I have learnt very outstanding points. For example, the programme used very sustainable number of working staff and social workers, the sites were very friendly at the methadone clinic, the nursing were very welcoming to patienrs. All patients, all social workers are very friendly and outgoing. When I go back I will try to motivate my staff more and share what I have learnt during this site visit.”

Best practices of Alliance activities in the various aspects of TB programs are presented in the publication of the World Health Organization (WHO) Regional Office for Europe “Good practices in strengthening health systems for the prevention and care of tuberculosis and drug-resistant tuberculosis”.

Alliance represents Ukraine with its unique experience in supporting patients with multidrug-resistant tuberculosis (MDR-TB) at the outpatient stage of treatment. Within Alliance cooperation with the Ukrainian Red Cross Society with support of the Ukrainian Center for Disease Control of the Ministry of Health of Ukraine, great progress was made in significantly reducing the rate of treatment interruption among the patients with MDR-TB. To promote treatment adherence among MDR-TB patients treated with second-line drugs in outpatient settings, daily follow-up care was delivered by nurses of the Ukrainian Red Cross Society. The package of services included the arrangement of high-quality DOT services brought close to patients aimed at preserving the customary way of life for patients to the maximum extent possible. Such services included delivery of medications and control over their administration at home or in another place convenient for patients and distribution of food packages among all patients who adhere to treatment twice a month. Besides, all patients received medical and psychosocial support during the whole period of treatment, which increased treatment success rate up to 85.6% as compared to 37% among those patients who did not receive such support.

Another best practice of Alliance included into the Health Service Delivery section is dedicated to early detection of TB among vulnerable groups. Taking into account that TB incidence in vulnerable populations is 10 times higher than the estimated incidence among general population, in 2013-2014 Alliance launched services of early TB detection in vulnerable populations. In cooperation with regional NGOs, questionnaires to screen for TB symptoms were introduced among clients at the high risk of this disease, and also a referral system was developed to guide patients in the healthcare system. One of the significant factors defining the success of early TB detection thorough screening among vulnerable populations is relatively low cost of this intervention.

WHO Regional Office for Europe also marked Alliance practice of TB treatment concomitantly with opioid substitution therapy (OST). Considering that over 40% of patients who receive OST are HIV-positive and almost one third of them also have TB, Alliance opened OST sites in TB treatment clinics. It allowed improving the access of people who inject drugs to health care, treatment of drug dependence, HIV and TB. People who inject drugs require a special approach to the treatment of TB, especially MDR-TB, but not all TB treatment facilities were ready to open their doors to such patients. An advantage of this approach is that it ensures effective cooperation between the TB and drug treatment services, which, in its turn, allows using an integrated approach to providing services to patients.

Read more about those and other good practices in prevention and care of tuberculosis.