MUNICH – While new HIV infections in 2023 plummeted globally to the level that they were in the late 1980s, they have surged by 20% in Eastern Europe and Central Asia since 2010, according to UNAIDS.

There were 140,000 new HIV infections across Eastern Europe and Central Asia in 2023, with 93% of new cases occurring in Russia, Ukraine, Uzbekistan, and Kazakhstan, according to the UNAIDS global report released on Monday ahead of the International AIDS Conference in Munich, Germany.

Since 2010, there has been a 20% rise in new HIV infections and a 34% increase in AIDS-related in Eastern Europe and Central Asia – while over the same period, 59% fewer people acquired HIV in sub-Saharan Africa – traditionally the worst affected region in the world.

Restrictive legal environments obstructing progress

“Restrictive legal environments and stigma are obstructing progress in the region,” said Eamonn Murphy, UNAIDS Regional Director for Eastern Europe and Central Asia.

“Restrictive laws, along with aggressive policing and stigma, push people away from medical care. If people are pushed underground, the HIV response will not succeed.”

Only half of the 2.1 million people living with HIV in Eastern Europe and Central Asia are on treatment, and only 42% of those living with HIV have suppressed viral load – the lowest rate globally. People with suppressed viral loads don’t pass the virus on to others.

Almost all new infections (94%) are in what AIDS researchers term “key populations” – men who have sex with men, people who inject drugs, and sex workers – and their sexual partners. Yet only 12% of resources are dedicated to prevention programmes for key populations.

All 16 countries in the region criminalise sex work, 13 criminalise the non-disclosure, exposure, or transmission of HIV, and seven criminalise small amounts of drug possession for personal use.

Only 43% of gay men, 52% of people who inject drugs, and 58% of sex workers get HIV prevention services. 

“The criminalisation of small amounts of drug possession for personal use, of sex work, and of HIV transmission and exposure, are driving the people most in need underground and out of reach of HIV services,” according to UNAIDS.

Nearly half the people surveyed who inject drugs in Kyrgyzstan and 32% of people living with HIV in Tajikistan reported avoiding medical care due to stigma and discrimination. 

“Supporting the leadership of communities is essential for reaching marginalised people and providing vital outreach services. Without community leadership and the integration of community services into the health system, reaching these groups is too difficult,” said Yelena Rastokina, lead of the ‘Answer-Kazakhstan’ Association, which represents women with HIV.

“The shrinking of civic space and attacks on human rights threaten our response to HIV, which is based on community-led or civil society-provided services. Addressing these interconnected issues is essential for a sustainable response to the AIDS epidemic in our region,” said Ganna Dovbach, executive director of the Eurasian Harm Reduction Association.

Several governments in the region are trying to eliminate the space for civil society which would make it almost impossible to reach key populations, Dovbach told a media briefing in Munich on Monday.

Georgia, for example, is in the process of making all civil society organisations that get more than 20% of their funds form abroad to register as “foreign agents”.

‘Without respecting human rights, we cannot defeat AIDS’

Speaking at a press briefing Monday at the opening of the 2024 conference, Andriy Klepikov, AIDS 2024 Regional Co-Chair, charged that Russia’s influence in the region is having ripple effects on stigmatization of LGBTQI populations and people who inject drugs – leaving them further than ever outside the circle of treatment.

“Eastern Europe and Central Asia have the least number, percentage, of people on treatment. Only 50%. This is a very worrisome signal,” he observed.

He called on other European governments and civil society groups to amplify calls to defend the rights of marginalized communities.   

“We have the Russian war against Ukraine. But actually what we have observed is a kind of hybrid war ….against evidence based science. We see that ideology stereotypes prevails over evidence based interventions,” he asserted.

“How many people are on opioid substitution therapy in Russia where 1 million people use drugs how many ? No one, not a single one. A WHO-recommended evidence based intervention is prohibited. How many people have access to clean needles and syringes? … Almost no one.”

“But why am I calling this a hybrid war? Look at what is happening in Central Asia where Uzbekistan, more recently Kyrgyzstan, and more recently in Georgia, where LGTBQI  populations are getting brutalized and criminalized. 

“In Russia, they say there are no transgenders. How you can treat people which not exist? 

“It’s very important to apply innnovations.. but without respecting human rights, we cannot defeat AIDS.”

However, Armenia is moving in a more positive direction, said the country’s health minister, Anahit Avanesyan.

“For us, an important change of pathway for the patients is to make more services affordable in primary health care. This means self testing. It means making ARV treatment affordable in the regions, not only in the capital,” said Avanesyan.

However, Russia’s war on Ukraine has strained her country’s resources as it deals with an influx of refugees equal to around 3% of the country’s population.

Dr Hans Kluge, World Health Organization (WHO) regional director for Europe, called for the normalisation of testing for HIV and sexually transmitted infections to address the problem.

“I’m very, very concerned about the situation in my region, particularly in the sub-region, which we call Eastern Europe and Central Asia, where we saw an increase in new HIV infections,”  Kluge told Health Policy Watch. WHO Europe covers 50 countries including the EU, Russia and the Balkans.

“This is a big paradox because we have everything. We have a preventive treatment which works. We have rapid diagnostic tools. We have an effective treatment, one pill a day. The issue is not so much medical, but societal in the sense that stigma and discrimination.”

He called for a massive scale up of HIV testing and the “decriminalisation of a number of policies” 

New HIV infections have increased by a staggering 116% in the Middle East and North Africa, albeit off a very low base, and by 9% Latin America since 2010. However, both regions have reduced AIDS deaths during that time.

Many of the AIDS deaths in Eastern Europe are being fuelled by a high prevalence of multidrug-resistant (MDR) TB. 

A study of TB/HIV coinfection using data from clinics in Belarus, Georgia, Latvia, Poland, Romania and Russia found that 19% of people newly diagnosed with TB had MDR TB and there was a 14% rate of TB recurrence. Over half the people with recurrent TB died.

Funding gap

A widening funding gap is holding back the HIV response. Approximately $19.8 billion was available in 2023 for HIV programmes in low- and middle-income countries (LMICs), almost  $9.5 billion short of the amount needed in 2025. 

Total resources available for HIV, adjusted for inflation, are at their lowest level in over a decade. The regions with the biggest funding gaps – eastern Europe and central Asia and the Middle East and North Africa – are making the least headway against their HIV epidemics.

“Countries in sub-Saharan Africa rely heavily on external funding for their HIV prevention programmes, whereas in eastern Europe and central Asia and Latin America, most of the funds spent on those programmes come from domestic coffers,” according to the report.

“World leaders pledged to end the AIDS pandemic as a public health threat by 2030, and they can uphold their promise, but only if they ensure that the HIV response has the resources it needs and that the human rights of everyone are protected,” said UNAIDS Executive Director, Winnie Byanyima.

“Leaders can save millions of lives, prevent millions of new HIV infections, and ensure that everyone living with HIV can live healthy, full lives.”

UNAIDS estimates the funding gap for Eastern Europe and Central Asia  to be 54%, 85% for the Middle East and North Africa; 65% in Asia and the Pacific and 16% in western and central Africa.

Around 59% of funding for HIV comes from countries’ own domestic budgets, but both international and domestic HIV funding are under stress, the report notes.

“Adjusted for inflation, domestic HIV funding declined in 2023 for the fourth year in a row, and international resources were almost 20% lower than at their peak in 2013. Financing support from bilateral donors has dwindled dramatically.”

The Global Fund to Fight AIDS, Tuberculosis and Malaria and the US government development assistance for HIV are the key bulwarks against further regressions. However, many countries in Europe and Central Asia do not qualify for Global Fund or Gavi assistance because of their middle-income status.

Money is Europe is tight because of Russia’s war against Ukraine. German State Secretary to the Federal Minister of Health Dr Sabine Dittmar said that her country was committed to funding UNAIDS at the same level and that her health budget had not been cut, although the budget for the development ministry had been cut.

Progress in sub-Saharan Africa

Despite the setback in Eastern Europe and Central Asia, worldwide almost 31 million people were receiving lifesaving antiretroviral therapy (ART) in 2023.

The 39% decline in new HIV infections globally is due “primarily to progress achieved in sub-Saharan Africa”, according to the report. 

Between 2010 and 2023, there was a 59% reduction in new infections per annum in eastern and southern Africa and a 46% reduction in western and central Africa.

In sub-Saharan Africa, life expectancy has jumped from 56.3 years in 2010 to 61.1 years in 2023.

“For the first time in the history of the HIV pandemic, more new infections are occurring outside sub-Saharan Africa than in sub-Saharan Africa,” the report notes.

South Africa runs one of the biggest treatment campaigns in the world. Almost one-fifth (19%) of all people on ART worldwide are in South Africa. In 2023, the country’s HIV programme was providing treatment to 5.9 million people, about 77% of all people living with HIV in the country. 

Over 90% of the people receiving treatment in South Africa in 2023 had a suppressed viral load. 

“This massive treatment programme has led to a rebound in average all-person life expectancy, from 53.6 years in 2004, when the treatment rollout began, to 65.9 years in 2023,”notes UNAIDS.

However, HIV incidence in girls and young women aged 15–24 years is “extraordinarily high in parts of sub-Saharan Africa”, according to the report.

“Prevention programmes and efforts to reduce gender inequalities, violence against women and harmful gender norms are not having a big enough impact,” it notes.