1. Controlling HIV/AIDS in Russia: Strategic Chokepoints & Opportunities Olusoji Adeyi Health Program Team Leader for Russia The World Bank, Washington, DC October 4, 2002 Presented at Center for Strategic and International Studies (CSIS) Conference on The Second Wave of the HIV/AIDS Pandemic by

2. A Snapshot The problems Large and fast- growing epidemic Stuck at the pilot phase: why? Non-financial limitations Financial limitations Opportunities Promoting a more positive environment Doing what counts - - the centrality of science Relieving systemic constraints Building skills Ensuring adequate $$$

3. Russia has a unique combination of: Strong legacy of health services in the socialist model Long-established institutions Membership of G8 Fast-growing epidemic of HIVAIDS Large burden of TB So far, a weak response to the epidemics

4. HIV/AIDS in Russia: Big & Growing 214,090 registered HIV +ve [Source: Russian Federal AIDS Center, 2002] Still a relatively small % of population, but Rapid spread among high-risk groups, particularly high-risk youths Evidence of spread into bridge populations Increasing heterosexual spread (6% in 2000, 15% in 2001) Likely spread into general population

5. Cumulative reported HIV infections per million population in Eastern European countries: 1993-2001 Belarus Estonia* Kazakhstan Latvia Lithuania Moldova, Republic of Russian Federation Ukraine 0 300 600 900 1,200 1,500 1,800 199319941995199619971998199920002001 Projected Cases per million population * actual 2001 year-end data Source: National AIDS Programmes (2001) HIV/AIDS surveillance in Europe. Mid-year report. Data compiled by the European Centre for the Epidemiological Monitoring of AIDS From UNAIDS and WHO. 2002.

6. How has it spread? (Cumulative, as of September 2002) Routes % Injecting drug users:53.9 Unknown40.9 Mother-to-Child 1.4 Heterosexual 3.2 Men having sex with men 0.4 Nosocomial 0.1 Source: Russian Federal AIDS Center, 2002

7. Major factors fueling further spread Behaviors IDUs sharing needles/ syringes Unsafe sex.. High prevalence of STIs … and, indirectly …. Very weak prevention efforts Increased vulnerability in the post- socialist era

8. Potential Economic Effects Declining GDP Declining investment Decrease in effective, i.e., quality- adjusted, labor supply Source: Ruehl et al., 2002, http://www.worldbank.org.ru/eng/group/hiv/

9. Stuck in pilot projects: what prevents large-scale programs? Inadequate attention to HIV/AIDS at high levels, but this is improving … slowly Legal and regulatory obstacles Social taboos Inadequate financing Limited implementation capacity

10. What is needed in Russia? High impact prevention Targeted interventions for high risk groups (e.g., IDUs, sex workers, high- risk youths) Harm reduction is key Surveillance & mapping 100% condom use Diagnosis and Treatment of STIs Safe blood pMTCT Care and Support VCT Palliative treatment Diagnosis and treatment of opportunistic infections ARVs.. Based on sound protocols, with good laboratory backup Social support

11. Opportunities for effective support to Russia

12. Promote a more positive environment for AIDS control Encourage / broker high-level commitment Between governments Through professional associations Through international organizations Promote reforms of the judicial system Crucial for prevention among IDUs Reduce effect of prisons as epidemiological pumps

13. Doing what counts: the centrality of science Crucial, for maximum impact on epidemic: # 1. Interrupt transmission among high-risk core transmitters #2. Prevent spread from high-risk core transmitters to bridge populations Desirable, but with less epidemiological impact: #3. Generalized information and advocacy by itself Ineffective: Moralizing & calls for total abstinence: wishful thinking

14. The central role of science: four key elements for tackling HIV/AIDS Surveillance: well-trained investigators Superior laboratories and staff Effective communications technology Public trust.. policy & advice based on evidence

15. Technical partnerships to ensure effective public sector roles Oversight: policy, program design, evaluation Direct public sector activities in some aspects Surveillance: epidemiological, behavioral, virological Scientific infrastructure to support prevention & care Laboratories, training Commissioning clinical trials Integration into economic policy Focus on outcomes, not on inputs

16. Ensuring adequate financing Estimates of incremental resource requirements Diagnostic equipment and supplies - - all levels Condoms Laboratory infrastructure for HAART

17. Conclusions: doing more & doing better What? Cost-effective interventions Supporting infrastructure and institutions How? Support local leadership to make programs possible Improved financing - - domestic and external Strengthening management & implementation skills Inclusion of multiple sectors as necessary