AIDS in Ukraine

Interview with Anja Teltschik in Fall 2005

For several years now Anja Teltschik has been working in leading positions for national and international aid organisations in the field of Public Health and HIV/Aids. Since early 2003 she lives and works in Ukraine.

Question: How do you assess the current situation in the AIDS care in Ukraine, now that the second tranche of the Global Fund aid has reached Ukraine?

A.T.: That depends, if we're looking at the field of prevention or at the field of treatment. Currently about 2,700 patients in Ukraine are treated with antiretroviral drugs. Right now the main problem is that most of the funds for the treatment come from the GFATM [The Global Fund to Fight AIDS, Tuberculosis and Malaria], that is, an international financing institution, while government investments remain to be the exception. The extension of the treatment proceeds too slowly, while in addition to the most affected areas further areas have been included in the treatment program. An additional problem is that we're just starting to introduce substitution therapy in Ukraine, that is, we are talking about pilot projects, which will have to be evaluated first, before an area-wide coverage can be achieved.
In the field of prevention the problem remains that there is no sound coordination. The prevention projects implemented within the framework of the GFATM project focus mainly on injection drug users and prostitutes in the eight main priority regions. But the following expansion, i.e. to transfer the experiences from these projects into other areas, hardly ever takes place.
In the field of psychosocial care and assistance a recurring problem is that many patients have no sufficient advance information about the treatment with antiretroviral drugs, and people are very biased against the treatment. The All-Ukrainian Network of People Living with HIV/AIDS only started last year to increase its educational work in this area and still a lot needs to be done. Right now our organisation (AIDS Foundation East-West, AFEW) is implementing a first mass-media campaign together with the Network to inform the population about HIV testing and the possibilities of a therapy. At the same time people living with HIV/AIDS and potentially affected people get specific information.
Because in Ukraine, the cart was put before the horse, in a manner of speaking. First, one saw to getting the medication into the country, next the treatment teams were hurriedly trained, and only now we're starting to prepare the population accordingly, and that, of course, is difficult.

Question: Because it had to happen so quickly, or why is that?

A.T.: Yes, we were all under pressure - the GFATM as well as the local organisations. Ukraine is one of the countries with the highest HIV infection rate in Europe; hence everybody was under pressure to introduce the antiretroviral treatment as soon as possible.

Question: How do you rate the perspective for post-2008, when the Global Fund aids will expire?

A.T.: The perspectives for the people who received and will continue to receive the antiretroviral treatment until 2008 via the GFATM project still remain unclear, because so far the government has not guaranteed the funding. In my opinion, the GFATM and others must increase the pressure and reach an agreement that secures the treatment. As you well know, we're talking about a lifelong treatment here. According to the government the number of people, who will start with the treatment next year in Ukraine, is minimal: and so far we haven't seen any long-term schedules. But we've got a new minister; hence it's still too early to say, what the government position will be on that subject in the time to come.

Question: But has Ukraine got the money to continue the funding, at all?

A.T.: That, of course, is the big question. I think that depends above all on the pricing policy. The African example has made obvious, that the treatment not necessarily has to be as expensive, as is the case in some parts of Europe. On the other hand, Ukraine is not the poorest of all European countries. It is also a matter of priorities and assigning resources. I think that Ukraine definitely would have the funds available. And it is unethical for government to first support a project like the GFATM project, and then to abort the treatment of so many people, when it finally expires.

Question: Please tell us about your prison project. What is the situation there like?
A.T.: So far our organisation has no prison project in Ukraine. But last year we (here: AFEW) assessed together with the Federal Penal Service the need, especially in the educational sector. Our organisation does, however, conduct prison projects in Russia and in Central Asia, and given the need, it would be important to initiate a project in Ukraine too. The more so, since Ukraine has the second highest imprisonment rate in Europe, and like all-over Eastern Europe and Central Asia, the number of injecting drug users is high in the prisons. Thus we assume, that a considerable amount of inmates is living with HIV/Aids. But I don't have any definite, publicly accessible figures regarding the amount of affected people in prisons. Among other things, that is due to the fact that in Ukraine HIV testing is voluntary.

Question: Can you tell us something about the penal conditions?

A.T.: All over Eastern Europe, including the prisons I visited myself, that strictly depends on each prison and its director. The differences are vast. In some prisons the standard is acceptable, in others not at all, especially regarding the prison hospitals. Many prison wardens of the state prisons are perfectly aware of that and hence quite open for co-operations.

Question: What exactly do you plan to do in the prisons?

A.T.: Some prevention programmes have already been introduced in Ukrainian prisons. Unfortunately most of the projects have not been institutionalized, especially where education is concerned. There is a network of regional education centres, which are attached to a national centre. And this is exactly where we would like to begin. In doing so, we wouldn't merely focus on HIV prevention but health promotion in general, to cover adjacent areas as well. Following steps would be to tackle the subject of treatment in prisons and helping inmates after their release, as well as providing assistance with re-integration. But, like I said, these are merely plans, which all still require funding.

Question: Is it true that the discrimination of prison inmates in Ukraine is much worse, than in Western Europe? Would you agree to that?

A.T.: Basically I'd say that discrimination of people with HIV/Aids in Ukraine, Eastern Europe and Central Asia still is in general much higher than in Western Europe. I would not just apply that to prisons, but characterise it as a basic issue. That is why our organisation conducts large-scale solidarity campaigns in cooperation with the All-Ukrainian Network for People Living with HIV/Aids. And if we look back twenty years, things were not any different in Germany. Changing attitudes and behaviour is a lengthy procedure.

Question: Many of the inmates are sentenced for drug use and drug possession. That is very closely linked to our subjects, because according to a new decree, you can get a prison sentence of 2 to 3 years for the possession even of a minimal drug amount for. What will be the impacts of that?

A.T.: The prisons in Ukraine are even now filled beyond capacity, with HIV and tuberculosis being a big issue. Should the imprisonment rate still further increase, these problems will increase as well and it will become increasingly difficult to get them under control.

Question: For one thing, there a lot of public funds and strategies coming from the Global Fund, to keep people exempt from punishment, to introduce substitution programmes and a democratic line; and for another, it seems to me, that the Ukrainian state pursues the reverse trend of stronger persecution. Are those two positions also working in opposite directions within the Ukrainian government?

A.T.: Like in any other government, and even more so in Eastern Europe, there are always various trends and this subject has not yet been concluded. So it would be still too early to talk about the consequences, because right now the discussion in Ukraine is still in full swing and the country currently experiences a government crisis. There are new ministers, a new cabinet, at the present time it is hard to say, how things will turn out. Next year (2006!) a new parliament will be elected. These elections will also have an impact on the situation. It is, however, our impression right now, that due to the upcoming elections a great stir is caused about things that basically don't really matter (in this context). Opinions always differ, just look at the topic of substitution therapy. We will have to wait and see, how the new ministers and the new cabinet will confront these issues, for the time being that is not conceivable. Likewise we are not yet familiar with the position of the new health minister, so it is too early to talk about future developments.

Question: We went to a colony in Donetsk. There we were presented with very progressive and clean utilities. However inmates then told us about completely different sides, and the institution turned out to be nothing but a façade. Is this not a great threat for your projects?

A.T.: No, not for our projects, because we neither had this problem in Russia nor in Central Asia. For one thing, we're not journalists, and for another, we stick to the rules, when we are asked not to go public with certain facts. Everybody has his rules, and if we want to work here and really want to change something, we have to observe these rules. We can point out to the need to change the rules, but that's how far it goes in most cases. Fortunately we didn't come across those problems so far. I think it's a remnant of the former Soviet times, to show the press as a rule rather the beautiful side. We were very surprised in Russia, how frank the Ministry of Justice was with us, given we are a NGO. It was similar in Ukraine, when we determined the requirements.

Question: That is something, I reckon to be difficult. Everything you do in the programmes is so very humane, especially in relation to what we have heard about the situation in the Ukrainian camps, that is, the inmates are treated very humanely. Isn't this a violent contrast to the brutal power structures within the prisons both, between jailers and prisoners as well as within the hierarchy of the prisoners?

A.T.: In Russia our organisation's programme includes, for instance, the approaches of peer counselling and peer education among the inmates. Important is, to start with the convincing at the top and provide an understanding for the approaches planned. Because if there is no insight in the government or on top of the prison structure that the problem is really a big one and cooperation with a NGO is required to deal with the issue effectively, you won't be able to change much on the lower levels. We don't say it is easy. If you'll look at our projects in Russia and Central Asia you'll see that the work of years is behind it. Therefore AFEW is primarily involved in long-term projects, because we know from experience that you can't change quickly powerful hierarchic and traditional structures, like the prison system. That takes years and in Russia, we had to start from scratch.

Regarding the issue of the inmates among themselves: in my opinion and from my personal experience in other countries too it is not a specific Eastern European problem that prisoners are having difficulties with each other. I've seen that too in the Western European prisons where I have worked. For instance, there are repeatedly frictions when prisoners arrive from abroad. I think everybody knows that a lot can happen in prisons. If we train peer counsellors, that is always a big deal. Often the internal stigmatisation and discrimination among the inmates has to be dealt with first, before the subject of HIV can be tackled successfully.

Question: We have heard that the prison officers are among the main dealers, due to the fact that they have a very low salary, which is hardly enough to make ends meet. In many sectors of the modern Ukrainian society corruption is today not the exception, but for many people a condition of life. Are you afraid of getting into conflict with those structures, when you start to pursue an anti-drug policy in the prisons?

A.T.: Anti-drug policy does not exactly belong into the scope of our duties. We are an organisation that primarily tends to HIV/Aids and corresponding co-infections, like for instance tuberculosis. We are concerned with the subject of drugs inasmuch as it has to do with the subject of HIV. That obviously includes needle exchange programmes. But, for instance, in Russia it is not possible to exchange needles. Thus we had to focus primarily on the topic of cleaning the needles and the injection equipment. And likewise in Ukraine it is still a long way to needle exchange programmes and substitution therapy in prisons. But our approach is harm reduction and not anti-drug policy. _There are other organisations, which see to this issue in specific.

Question: But as soon as you start with a substitution programme to increase or maintain the adherence, you'll get into this range?

A.T.: That is true in part. Only just now, we are far from ready in the Ukrainian prisons, we have only just started with the pilot projects on substitution therapy outside the prisons, within the scope of antiretroviral therapy. Naturally you get on the wrong side of dealers, once you introduce substitution programmes. There will always lurk dangers when you work in this field. This is something we experienced especially with our outreach workers, who receive a special training, because even if they only provide information and condoms, they are exposed to danger, given that they work with target groups who live on the margin of society, who are often criminalised and persecuted or also in contact with thugs. Our organisation is also active in qualifying social workers and [other] people working in this field, since the security of the staff is an ever-recurring subject. That doesn't apply to prison work alone. Due to our experiences in Russian and Central Asian prisons, it is sometimes easier to protect [people] within a rigid system with the help from above, than on the streets, where they are subjected to everything without any protection. The police is seldom just around the corner, and not always very cooperative, if something happens, while in prison, there are at least certain structures making work there less dangerous. Our outreach work in Russia has certainly been more dangerous than the prison work.

Question: How can you avoid that almost a whole section of the population falls out of the system due to permanent incarceration? You mentioned before that in the government as well as in society different powers are clashing. Is there a tradition of incarcerating disagreeable people?

A.T.: That was definitely the case in the former Soviet Union and the problem still remains in some Eastern European states. Being a NGO, our hands are often tied here. We can point out time and again to the wrongs, but often our voice doesn't carry any weight. Plus, we are no important donors like GFATM, whose voice carries more weight merely due to its function. Being a_ NGO you always have to re-approach the other side and stay in contact. Here in Ukraine new structures have been created with the new government and the introduction of the National Coordination Council, which now enable NGOs to have a powerful voice and to promote, for instance, needle exchange programmes in prisons. It is still not clear how the new deputy prime minister will continue the Council's work, but at least there is a basis for talks and discussions.

Question: Well, it is one thing that outreach workers are locally threatened, but I can imagine that in general parts of the general population have a very low opinion of inmates and former convicts and don't approve of dealing with those people, or of working with them, let alone helping them with very expensive drugs. Is that something you experience too?

A.T.: Yes, that is an issue. Because like I mentioned before, stigmatisation and discrimination can be found in any Ukrainian population group. Even the people working for the ones affected, are not by no means clear of that. A study about health care professions made obvious that in specific in this area discrimination is a common aspect. A view shared by the Ministry of Health. It is a long and difficult process of change and reorientation, which on the whole started rather late in Ukraine.

Question: Is it possible that other health sectors are simply jealous of all the funds flowing into the AIDS sector?

A.T.: Definitely, because there are a lot of other health problems and issues, aside from the HIV and TB epidemic. And like in any other country, resources are limited and every year there is a battle for funds. Even employees of the health ministry working in the HIV/Aids sector occasionally ask, if it wouldn't be advisable to invest more into other sectors. _Even so it is a big step forward, if this is discussed openly and you don't meet with an immediate refusal.
Sure, it is an urgent matter that the government increases the investment in prevention, treatment and psychosocial care. It is not enough, and in my opinion would even prove to be a mistake in the long run, if most services in the HIV/Aids sector would only be funded with Western funds. Within the framework of the World Bank project the Ukrainian government made an additional investment, but unfortunately the projects continues to stagnate. The government must invest more and there have to be guarantees for patients living with HIV/Aids that their treatment well be continued without charges even when the international programmes have expired.

Karsten Hein conducted this interview in October 2005 within the scope of shooting his second film about AIDS in Ukraine.

August 29, 2006 | Category: Background