on the Status of HIV/TB/HCV Prevention and Treatment and OST Programs in Donetsk and Luhansk oblasts
(as of 29 May 2017)

Alliance for Public Health took an active part in 25^th Harm Reduction International Conference, which was held in Montreal on 14–17 May 2017. This is a key conference for harm reduction experts, researchers, activists, and members of vulnerable communities – people who use drugs, sex workers, and men who have sex with men. For four days, the capital city of the only French-speaking province of Canada celebrating its 375^th anniversary became a think tank, summing up the results and defining the key agenda for future years. The conference was attended by over 1,000 delegates from more than 70 countries of the world. 40 sessions, 25 dialogue spaces, 8 workshops, 26 video and film sessions, over 20 exhibition halls, 3 award ceremonies – they all clearly demonstrated the global harm reduction trends and formed a diverse program for community activists and harm reduction experts.

Alliance for Public Health played an active role in the conference, delivering four oral and six poster presentations.

Anton Basenko, the Country Focal Point: PITCH Project as a Board Member of the International Network of People Who Use Drugs (INPUD), representing the Eurasian region and the ENPUD, delivered a speech at the traditional INPUD meeting, which always precedes the conference, presenting the position of the PUD community and defining clear messages for the global community on harm reduction issues. “Two years, which passed from the previous conference in Kuala Lumpur, were very challenging both for the INPUD and for our region, – he said. –  But today, reporting on the previous years, we have an honor to welcome the new board, the new executive director and the new strategy, to which the EECA PUD community addresses its problems, needs and proposals, being confident in real support from the side of our international brothers and sisters.”

Presentations at the conference demonstrated the successful experience of Alliance in harm reduction. In particular, Pavlo Smyrnov, Deputy Executive Director: Program shared the successful experience in implementing the biggest in the region harm reduction program, covering approximately 250,000 drug users. Besides, Pavlo Smyrnov presented harm reduction as a platform to scale up access to HIV care for PWID as well as best practices of the Alliance for Public Health, including Community Initiated Treatment Intervention (СІТІ) and Optimized Case Finding (OCF), which received positive feedback and prompted numerous questions from the audience on the possibility to implement such approaches in other countries. It is good to know that the experience of Alliance and Ukraine has been again recognized at the international level. Pavlo Smyrnov’s presentation was preceded with a speech delivered by Annette Verster, representative of the WHO headquarters, who on several slides gave the example of Ukraine in the context of availability and highest quality of data on the cascade of services and the national estimates on key populations: “I would like to thank Ukraine as the work of WHO is based exactly on such adequate country data as only having reliable data along the cascade we can clearly understand where the world is on its way to the global 90-90-90 targets”.

An important topic discussed at the conference was drug policy reform and decriminalization of drug users. Pavlo Skala, Associated Director: Policy and Partnership in his presentation “Police and Harm Reduction” presented the most recent developments and effective approaches in cooperation with the national police at the responsible stage of its reformation. Invaluable experience of Alliance in conducting all-Ukrainian testing of representatives of defense and law enforcement agencies for viral hepatitis C (over 4.5 thousand people were tested for HCV in 2015), further use of self-testing using rapid tests during educational workshops for police officers in combination with demonstration of new awareness-raising harm reduction videos (developed by the UNODC Office in Ukraine in cooperation with civil society organizations implementing harm reduction programs), along with the interest of the audience to the ways of responding to challenges in the spread of HIV and HCV epidemics in the east of Ukraine sparked a big interest in the conference participants.

Another highlight of the conference was presentation of the activities of the National Substance Abuse and OST Hotline as an effective human rights, advocacy and awareness-raising mechanism – the experience of activities implemented by members of the PWID/OST community with support of the Alliance was presented by Svitlana Tkalya, head of a partner self-organization of OST patients and parents – Hope and Trust NGO. This is the only Ukrainian implementing partner organization, which won the right to make an oral presentation at the conference. Even Australia and the UK are looking closely at such experience in the context of launching similar mechanisms in the peer support format.

The posters presented by Alliance representatives and its partners at the conference were also very interesting and informative:

• Positive dynamics or the real situation with the drug users’ criminalization level in Ukraine? (Pavlo Skala, Natalia Kravchenko, Andriy Tolopilo)
• Access to HCV treatment for key populations in Eastern Europe and Central Asia (Ludmila Maistat, Natalia Kravchenko, Pavlo Skala)
• Increasing the impact of harm reduction programs in response to HIV and HCV epidemics through integrated approach of testing with linkage to care and treatment (Natalia Kravchenko, Ludmila Maistat, Pavlo Skala)
• Strategy to scale up access to HCV testing and treatment  for PWIDs in Ukraine (Pavlo Skala, Ludmila Maistat, Natalia Kravchenko)
• Implementation study informs innovative intervention for adolescents who use drugs in Ukraine (Iana Sazonova, Vyacheslav Kushakov, Iryna Zharuk)
• “On the way to NSP in prisons.” Implementation of harm reduction services based in probation service, Ukraine (Anton Basenko, who was in the focus of attention during all days of the conference, in particular attracting greetings and questions from representatives of the Ministry of Health and Social Services (Quebec) and the Correctional Service Canada as Canada is the country that gives multimillion support to reform the penitentiary system of Ukraine).

Besides, the conference included a side event “Future Proofing Harm Reduction” focused on sustainable development goals. One of the speakers at this event was Marina Braga, Senior Manager: International Technical Support. She presented the project for adolescents who use drugs implemented by Alliance and its partners with support of the Elton John AIDS Foundation. “Harm Reduction International 2017 demonstrated that even in such a progressive country in terms of access of people who use drugs to services and their quality as Canada there are issues and challenges, which makes the community of activists build bridges between stakeholders and call high public officials to quickly respond to changes in the drug scene and recent scientific developments,” – underlined Marina.

Alliance representatives had an opportunity to promote Harm Reduction Academy – an international training course to educate harm reduction experts, the next cycle of which is scheduled for September 2017.

The conference allowed summing up the existing experience and expertise, defining challenges as well as new trends which would influence the development of drug policy and harm reduction in the nearest years. The topics which are gaining momentum or are among the new trends are access to HCV treatment among PWID, gender approaches, new drugs and changes in the global drug scene (synthetic opioids (fentanyls) and stimulants (e.g. mephedrone) and their consequences (overdose, diseases, mortality), new forms of naloxone and new consumables for harm reduction among people who use non-injecting drugs, new internet-based harm reduction approaches, “chemsex” (using injecting and non-injecting substances in sexual context), addiction therapy with ibogaine and other psychedelic substances (ayahuasca and others). Crisis with the “boom” of opioid overdoses and deaths caused by the spread of such dangerous synthetic substances as fentanyl and carfentanyl in Canada made the Canadian PWID community turn their backs to the Canadian Minister of Health, Jane Philpott, at the opening ceremony of the conference with “They Talk We Die” banners, calling to urgently solve the problem.

The National TB and HIV/AIDS Council approved the country proposal to the Global Fund with the total budget of USD 119 million for TB and HIV response in 2018-2020. It was unanimously resolved that three principal recipients of the grant within the proposal will be the Public Health Center of the Ministry of Health of Ukraine, the Alliance for Public Health and the Network of People Living with HIV. For the first time, delegates from the communities of key populations – people who inject drugs, men who have sex with men and sex workers – took part in the meeting of the National Council as its full-fledged members.

The structure of the proposal is based on the gradual growth of the country leadership, with relevant increase in the financing of the Global Fund. Pavlo Rozenko, Chair of the National Council underlined: “The new proposal includes financing activities aimed at overcoming the epidemics of HIV and tuberculosis, improving the quality of services and expanding the opioid substitution treatment. The underlying strategy of the proposal stipulates the mechanism of step-by-step transition of the responsibility for implementation of the program activities from three recipients of the grant to one recipient – government”.

“We appreciate cooperation of the government sector with non-government organizations: together, we will be able to achieve the ambitious goals set forth in the proposal to the Global Fund. We expect that in the course of implementation of the three-year program the share of state funding, in particular aimed at working with the populations most vulnerable to HIV, will be growing”, pointed out Andriy Klepikov, Executive Director of the Alliance for Public Health.

The proposal is to be submitted to the Global Fund on 23 May at the latest, and the final decision of the donor is expected in summer.

For the first time, Alliance for Public Health made an analysis and would like to present data on the real scope of legal and illegal circulation of opioid substitution therapy (OST) drugs in Ukraine.

Alliance has been implementing OST programs since 2005, regularly providing evidence of efficiency and safety of harm reduction approach as opposed to ungrounded accusations on allegedly high volumes of OST drugs leakage.

During 12 years of OST program implementation in Ukraine, almost one and a half tons of OST drugs were delivered to licensed healthcare institutions to cover the needs of the program. The scope of OST drugs leakage recorded in court judgments is less than 0.002% of the total amount of drugs delivered.

Organizers of The First Sex Workers March, held on 3 March in Kyiv, officially sent their draft law to the Chairman of the Supreme Council,  President and Prime Minister of Ukraine calling to immediately abolish the administrative responsibility stipulated in art. 181-1 of the Code of Administrative Offences of Ukraine (for prostitution) on the eve of the Eurovision Song Contest 2017.

In the official letters, which have been sent today to all the three government bodies on behalf of the first national union of sex workers – All-Ukrainian League “Legalife” – and Alliance for Public Health, it is stated that the threat of administrative prosecution is traditionally used by criminal mobs and corrupt law enforcers as a method of psychological pressure on sex workers, which often leads to mental and physical abuse.

Due to artificial criminalization and high level of stigma and discrimination, sex workers (their number in Ukraine being over 80 thousand according to the estimated data) are not able to effectively protect their rights. In this situation, sex workers do not have adequate access to reproductive health services as well as prevention and treatment of HIV and other dangerous diseases.

Authors of the initiative are concerned with the fact that on the eve of the Eurovision Song Contest 2017 which will be held in Kyiv and will be attended by tens of thousands of tourists, in particular from the EU countries, in most of which individual prostitution has been long ago decriminalized, the level of violence and inadequate treatment of sex workers from the side of public authorities and law enforcement agencies will expectedly increase as they will be trying to maximally “clean up” the capital city from “unwanted elements” as it traditionally occurred on the eve of EURO 2012, Eurovison 2005 and other similar events.

Organizers of The First Sex Workers March are confident that cancelling administrative responsibility for individual prostitution on the eve of Eurovision 2017 should become a powerful signal for the European community, which will confirm adherence of our country to the European values, in particular in terms of human rights protection in Ukraine. Such a measured and decisive step towards abolition of vestiges of the totalitarian past will allow bringing out of the circle of marginalization at least 80 thousand Ukrainian citizens, mostly women who earn their living with this hard work!

On 3 March 2017, All-Ukrainian League “Legalife” and the Alliance for Public Health with support of civil society organizations and with participation of human rights activists and mass media held the first Sex Workers March in the history of independent Ukraine along the route: Supreme Council – Cabinet of Ministers – Administration of the President of Ukraine. The main goal of the event was to draw attention of high government officials, general public and mass media to the need to abolish administrative responsibility for prostitution (art. 181-1 of the Code of Administrative Offences). Before the event, initiators for the first time presented their version of the proposed draft law, which today has been sent to relevant legislative bodies with official letters.

More information about the event can be found in media review of the Sex Workers March. 

Letter to President of Ukraine

Letter to Prime Minister of Ukraine

Chairman of the Supreme Council

Contact details for mass media:

 +38 050 3825178,

 +38 044 4905485, ext. 221

To end the TB epidemic, Ukraine has only one recipe – to implement quality people-centered TB care! This statement was made by Andriy Klepikov, Executive Director of the Alliance for Public Health at the press conference to mark the World Tuberculosis Day.

“Within its pilot projects supported by the Global Fund, Alliance proved that combination of medical, social and psychological support allows increasing MDR-TB cure rate twofold! 80% of patients with MDR-TB were cured! This is a really impressive result, considering that the average treatment success rate for such patients in Ukraine is less than 40%,” – informed the speaker.

Andriy Klepikov also underlined the need to move the function of patient support from donor funding to state and local budgets: “What may seem an additional service, is indeed an essential factor, which makes a significant impact on treatment success.” As a leading civil society organization, co-implementer of the National TB and HIV/AIDS Programs and one of the principal recipients of the Global Fund to Fight AIDS, Tuberculosis and Malaria, Alliance welcomes increased commitments of the state to fund the response to tuberculosis in 2017. But at the same time, our organization points out that the main task today is to guarantee that, as opposed to the previous years, the funds will be spent on the most effective models of care.

At the press conference “People-centered care – the key to ending the epidemic of tuberculosis in Ukraine!”, Olha Bohomolets, MP, Head of the Verkhovna Rada Committee on Public Health and member of the international movement of parliamentarians against TB, Global TB Caucus, told about the strategic plans to end tuberculosis in Ukraine. Thus, she underlined that to have an impact on the epidemic, Ukraine has to reduce TB morbidity by 25%, reduce TB mortality by 35% and increase MDR-TB cure rate at least up to 75%.

But to achieve those goals, the Ministry of Health needs to elaborate a step-by-step action plan and define economic indicators, such as the cost of care per one patient, and others. From her side, Olha Bohomolets told she guaranteed support of the Committee on Public Health in enhancing the response to TB and advocate to the deputies of Ukraine to allocate the required funds from the budget of Ukraine for such response.

Dr. Masoud Dara, Coordinator, Communicable Diseases and Programme Manager, TB, HIV/AIDS and Viral Hepatitis Division of Health Emergencies and Communicable Diseases, WHO Regional Office for Europe said that coordinated efforts of all stakeholders were essential to overcome the epidemic of TB. He also pointed out that it is critical to scale up access to MDR-TB treatment, in particular ensure: integration of people-centered care into the system of support for TB patients, development and availability of mechanisms of patient support, implementation of innovations in the current treatment models. Besides, Dr. Masoud Dara noted that special attention should be paid to the spread of HIV/TB co-infection and ensured that our country could count on the WHO support in launching effective approaches to ending the TB epidemic.

Patients diagnosed with MDR-TB told about their own experience of receiving people-centered care. “For me personally, people-centered care has a number of advantages. First and foremost, it ensures uninterrupted supply of effective drugs, – told Ihor Svachii, a patient who has been treated within social support program for almost a year. – The second important thing is that I get treatment at home. In a hospital, you feel isolated anyway, and I surely wouldn’t be able to stand it for two years. Emotionally, it is very difficult. At home you are in familiar settings. You’ve got a computer, a TV set, music, books. You can go for a walk. You can feel support of your friends and family, while they would have limited access to hospitals.”

We really hope that patients’ voice will be heard by decision makers and the society in general! People-centered approaches, actively implemented by Alliance, should become an integral part of the future TB care system and should make a decisive impact on the response to the TB epidemic.

Video of the press conference: https://youtu.be/Ssclfb525JM.

Ukraine is known for having a severe TB epidemic. It is one of the TOP 5 countries in the world with the highest burden of multidrug-resistant tuberculosis (MDR-TB): MDR-TB is detected in each fourth patient with newly diagnosed TB and in each second patient with TB relapses. Besides, Ukraine has the worst in Europe TB cure rates – only 71% of new TB cases and 39% of MDR-TB cases are cured. Generally, every year over 30,000 people in Ukraine are diagnosed with TB (four new cases every hour), with every eighth patient dying.

On World TB Day, Alliance for Public Health is presenting solutions that are making a major difference in a challenging TB environment, comprehensively addressing TB detection and treatment.

Diagnostics

Alliance is implementing a project aimed at early TB detection among most-at-risk populations. In 2016, over 160,000 clients were reached with screening survey, and 14,000 of those screened positive were examined for TB at healthcare facilities. Finally, 92% of those diagnosed with TB started proper treatment at healthcare facilities. In particular, addressing HIV/TB co-infection is our special focus.

Treatment access

With mobilized resources from the Global Fund and other donors, Alliance dedicated over half of its budget for addressing TB, mainly for procurement of MDR-TB medicines. In 2015-2016 only, we reached USD 34.6 million worth of MDR-TB drugs delivered in all regions of Ukraine.

As of January 1^st 2017, altogether 12,551 patients were enrolled to MDR-TB treatment within the program supported by Alliance with the Global Fund funding, and 5,535 of them continued receiving medications and social care from Alliance.

Treatment success

We proved that patient-centred approach with social support is not an additional element which might be added to standard medical MDR-TB treatment. It is a key cornerstone element of the successful MDR-TB treatment.

Within its pilot projects supported by the Global Fund, Alliance proved that combination of medical, social and psychological support allows increasing MDR-TB cure rate twofold. 80% of patients with MDR-TB were cured. This is a really impressive result, considering that the average treatment success rate for such patients in Ukraine is less than 40%.

Despite the growing challenges, Alliance continues its work on the temporarily occupied territories in the east of Ukraine. Alliance successfully delivered humanitarian aid, including MDR-TB treatment, for over 1,400 patients. We also support our 12 partner civil society organizations in Donetsk and Luhansk oblasts working to ensure early TB detection among most-at-risk populations.

Alliance applauds the governmental leadership and growing commitment to stop the TB epidemic. The result is our joint success based on the partnership with the Ministry of Health, State Centre for Public Health, Ukrainian Red Cross Society, Network of PLWH and numerous civil society organisations, community groups and medical facilities. We are greatly thankful to our international partners: The Global Fund, WHO, TB Europe Coalition, Stop TB Partnership, UN Secretary General Special Envoy on HIV/AIDS in Eastern Europe and Central Asia, United Nations Special Envoy on Tuberculosis, UNAIDS, Zero TB Cities, Global TB Caucus, PAS Center, US Government, PATH and other programs we are coordinating our response with.
Ukraine is currently developing a new proposal to the Global Fund for 2018-2020, with significant funding for TB. It is critically needed to scale up patient centred approach to all in need and eligible MDR-TB patients, to focus on missed TB cases and those lost to follow up. Over the new program, Alliance is planning to gradually transfer the civil society components ensuring patient-centred approach to the MDR patients currently funded by the Global Fund to the domestic funding. The newly approved by the Government 2020 Strategy to fight TB and HIV epidemics sets a good framework for this.

According to UNICEF estimates, in Ukraine there are 21,700 adolescents aged 10-18 years using injecting drugs with detrimental consequences for their health (no data on non-injectors). In the first half of 2015,  159,638 PWIDs accessed harm reduction services in Ukraine. Only 657 (or 0.41%) of clients served within this period were younger than 19 years. Vulnerable and neglected adolescents are most likely to use drugs. These include children whose parents abuse drugs or alcohol, or face other difficult family circumstances (are unemployed, single parents, parents who work long hours). Access to out-of-school activities is limited or very expensive so many adolescents spend considerable amount of their time unsupervised on the streets. Alliance for Public Health started an innovative project “Harm Reduction for Children and Young People Who Use Drugs in Ukraine” supported by Elton John AIDS Foundation.

On 20 March 2017, Practice Centre for HIV, Hepatitis C and Drug Use run by Alliance for Public Health organized a webinar “Harm reduction for adolescents who use drugs in Ukraine: reaching the underserved”. Iryna Zharuk, Project Coordinator presented the experience of Alliance for Public Health in implementing this innovative project. Participants of the webinar learnt about the intervention design, planning steps, networking and partnership, project activities, research component, challenges and how they are addressed. To listen to the webinar, follow the link.

A two-day meeting for Ukrainian experts in implementation of rapid change model for the improvement of addiction treatment (NIATx-RCM) was held on March 1–2 by ICF “Alliance for Public Health” within the research project “Expanding Medication Assisted Therapy (MAT) in Ukraine” within the partnership with the Yale School of Medicine (USA) with financial support of the National Institute on Drug Abuse (USA). Narcologists, nurses and representatives of NGOs who are actively involved in OAT scaling-up in Ukraine attended the meeting. 27 participants from 13 Ukrainian oblasts shared their experiences about progressive strategies of access and retention in OAT, namely: alignment of patients’ routes, peer-to-peer navigation, take-home care, prescriptions, advocacy and process efficiency of OAT drug dispensing. During nominal group techniques the special attention was paid to the barriers for scaling-up OAT services in Ukraine and the ways to overcome these barriers.

The project is implemented in strong collaboration with Ukrainian Institute on Public Health Policy and Public Health Center of the Ministry of Health of Ukraine.

On the International Sex Workers Rights Day marked on 3 March 2017, for the first time in Ukraine a group of civil society activists and sex workers with support of human rights advocates held a Sex Workers March, demanding to cancel administrative responsibility for prostitution   (article 181-1 of the Code of Administrative Offences of Ukraine). This day was announced as the national day of mourning for miners who died as a result of the tragic accident on March 2, so organizers (All-Ukrainian League “Legalife” and Alliance for Public Health) after a minute’s silence called on participants to proceed with the event in the format of a “silent procession”.

To draw the attention of public officials to the problem of violation of sex workers’ rights,  their stigmatization and violence towards them, marchers with improvised posters “My work is my choice!”, “Sex work is also work!”, “Taxes, not penalties!”, “armed” with red umbrellas and hard hats, masks, “certificates of sex workers” as well as some elements of their professional “workwear”, led their silent peaceful procession along the government quarter, heading their way from the building of the Supreme Council, past the Cabinet of Ministers, to the Administration of the President of Ukraine, which was the final point of the march.

“Currently article 181-1 of the Administrative Code is still used as a repressive instrument of corruption, extortion, intimidation and violence”, – said Yulia Dorokhova, leader of the movement for the rights of sex workers, lawyer of the All-Ukrainian League “Legalife”.

Threats to issue an administrative offence report for prostitution are traditionally used by corrupt members of law enforcement bodies as a means of psychological pressure on sex workers, which often leads to mental and physical violence as the legislation of Ukraine works against them, depriving them of their rights to human dignity and protection.

“In Ukraine, the laws are used to commit unlawful acts! I had to do “volunteer work” in police [provide sex services to policemen for free] for them not to issue an administrative offence protocol.  If I said no, they could have beaten me”, – confesses Olena, a sex worker from Zhytomyr region.

“Administrative responsibility for prostitution is one of the essential factors contributing to the spread of HIV epidemic in Ukraine. According to the joint estimates, today in Ukraine there are about 80 thousand of sex workers. Only in the capital city, there are almost 11 thousand of them. In the east of Ukraine, over 25 thousand people provide sex services to earn their living. The Supreme Council of Ukraine with billions of dollars in cash recorded in electronic declarations of people’s deputies, cannot continue to shamelessly ignore and marginalize a rather big group of Ukrainian citizens”, – said co-organizer of the event, Pavlo Skala, Director: Policy and Partnership at Alliance for Public Health.

Participants of the march brought to the Parliament, Government and President’s office a draft law developed by them on canceling the administrative responsibility for prostitution, calling people’s deputies to sign this legal document and submit it for consideration to the Supreme Council, rather than engage in “political prostitution” behind the scenes. Though this week the premises of Parliament was empty and quiet as the deputies are currently away “working with their voters”.

Recognized human rights organizations also supported the main demand of the marchers:

“People who provide sex services are one of the most socially unprotected populations in the world. They are very vulnerable to discrimination, violence and abuse of power. We advocate for complete decriminalization of all aspects of voluntary provision of sex services and call for comprehensive legal protection of sex workers from exploitation, trafficking and violence,”- told Oksana Pokalchuk, director of Amnesty International in Ukraine.

Media Coverage of Event