Eastern Europe and Central Asia

Mihai Ceban (not his real name) has been locked down at home since 17 March, when a state of emergency was declared in the Republic of Moldova in response to COVID-19. He is an information technology specialist, so working from home has not disrupted his daily routine too much. His was worried, however, by his inability to go out to get his supply of HIV pre-exposure prophylaxis (PrEP). He has been taking PrEP to prevent becoming infected with HIV since September 2019. Although he has a partner, he says taking PrEP makes him feel safer. “You can’t fully trust your partner,” he said.

During the state of emergency, restrictions imposed by the authorities and the fear of becoming infected with COVID-19 limited his social contacts to a maximum of two or three people. However, his partner continued to lead an active social life, which increased his risk of HIV infection. 

"The fear of COVID-19 was enhanced by the fear of getting infected with HIV. That's why, when I saw I was running out of my pills, I started worrying. I wondered what I would do if no one was working? How do I protect myself? The response came from the GENDERDOC-M Information Center, which delivered my PrEP at home. And the fact that it was delivered to me during the pandemic means that my right to health was respected. It’s my right to have an active protected sex life during the pandemic. And the delivery of PrEP services at home has brought psychological relief and reduced the anxiety of becoming infected with HIV,” Mr Ceban said.

Mr Ceban is not the only beneficiary of the PrEP deliveries. Alexandru Goja, a health programme consultant at the GENDERDOC-M Information Center, said that during the pandemic more than 90 people received PrEP deliveries at home. 

“At the beginning of the pandemic, everyone went into a kind of panic. Some people on PrEP discontinued taking it, but most wanted to continue. For them, we went out, into the parks, in front of their apartments blocks, where we tested them for HIV and delivered their medicine. During quarantine, people from key populations avoided going to medical institutions to pick up their medicines, trying to prevent the risk of becoming infected with COVID-19. The support provided by nongovernmental organizations helps them to exercise their right to health,” said Mr Goja. 

Angela Nagît, an infectious disease specialist at the Hospital of Dermatology and Communicable Diseases, agrees with him. During the pandemic, she carried out consultations and prescribed PrEP remotely. It is very important that once enrolled on PrEP, the person should stick to it, she said. 

“In the Republic of Moldova, HIV infection continues to be a major public health problem with a great medical, social and economic impact. Around half of the people who are estimated to be living with HIV don’t know their status. Unprotected sexual contact is one of the risk factors for HIV transmission. PrEP is a way to prevent infection, thus ensuring the right to health, especially for those from the key affected groups,” she said.

The lockdowns and self-isolations imposed to fight the COVID-19 pandemic have affected everyone, key populations and people living with HIV included. Prolonged isolation and limited contact with family and friends have increased anxiety and depression and impacted quality of life, increasing the need for mental health services.

To respond to this need, an online platform that offers psychological services and support for people from key populations has been launched in Kazakhstan. On it, people can get answers to questions related to different aspects of mental health, request professional consultations with psychologists or psychotherapists and receive broader information about health and well-being. 

“Anxiety, uncertainty, worries—these feelings are consequences of the quarantine and self-isolation during the coronavirus pandemic. For many people, the time spent in quarantine was difficult. Today, we see a greater need for psychological help and support. It was for this purpose that this platform was created for key populations,” said Nikolay Negay, Director-General of the Republican Scientific and Practical Center for Mental Health of the Kazakhstan Ministry of Health.

The platform was developed with the participation of people from community organizations, representatives of key populations and activists.

“During isolation, we supported each other as best we could through social networks, communication by phone, Skype, but there was a need for qualified professional help. We are glad that such assistance has become available, and for free. The resource is informative and answers many questions,” said Oksana Ibragimova, the acting President of the ALE Kazakhstan Union of People Living with HIV.

“An anonymous rapid needs assessment conducted by UNAIDS in Kazakhstan among people living with HIV and key populations found that around 60% of respondents needed psychosocial support during the COVID-19 lockdown. It was therefore decided to find a way to provide reliable information, advice and professional assistance to those who may need it,” said Gabriela Ionascu, UNAIDS Strategic Information Adviser for Central Asia.

The platform was created as an initiate of the Republican Scientific and Practical Center for Mental Health of the Kazakhstan Ministry of Health, with financial support from UNAIDS and technical assistance from the Kazakh Scientific Institute of Dermatology and Infectious Diseases of the Kazakhstan Ministry of Health.

When the son of Kymbat Toktonalieva (not her real name) was finally diagnosed with HIV after numerous visits to the hospital over many months, it was only the beginning of the fight.

Her husband left her, leaving her to look after their child on her own. She fought for her son and his rights, for justice. She went to court, attended rallies, wrote letters, worked with other like-minded people and helped other women in the same situation.

For the past six years, Ms Toktonalieva has channelled that campaigning zeal into working as a peer consultant in a multidisciplinary team in a family medical centre in Osh, Kyrgyzstan, helping people living with HIV to get services, providing support and motivating them to adhere to their HIV treatment. There are 10 multidisciplinary HIV teams in the country, which were formed by UNAIDS in 2013; they all include a specialist in infectious diseases or a family doctor, a nurse and peer consultants.

The peer consultants come from the same environments and backgrounds as the people who they work with and have faced similar problems. They may be people who are living with HIV or people who have been affected by HIV. They have decided to act, helping themselves and others, often serving as a bridge between the medical workers and people living with HIV.

“Working as a peer consultant has given me an opportunity to help people to overcome their problems, many of which I have come across myself in the past,” said Ms Toktonalieva.

The peer consultants work with the medical staff, directing, prompting, helping, talking and listening. They are trained to be non-judgemental and help people who have recently been diagnosed as HIV-positive to accept their status and to learn to live with the virus.

The role of the peer consultants is being expanded by the COVID-19 pandemic. From the very beginning of the pandemic they were in contact with people living with HIV, delivering medicine to people’s homes so they could stay on treatment during the lockdown, distributing food packages and providing psychological support.

Another peer consultant, Kalmurza Asamidinov, who works in Kyzyl-Kiya, said, “My work brings good, but I can’t say that everything works out perfectly. We work with different people. Some need to be persuaded to adhere to their HIV treatment because they don’t believe in the treatment, while others are tired of taking antiretroviral therapy—we have to find a different approach for everyone. People are increasingly in need of simple human communication. Many clients miss mutual help and the support groups, which we cannot provide during the COVID-19 lockdown.”

The peer consultants working in the 10 multidisciplinary teams each have a different story to tell. Mannap Absamov, one of the peers in the multidisciplinary team in Osh, said, “Initially it was difficult. We were not able to understand the medical staff, and they could not understand us. But slowly we found points of contact. The main thing is that almost simultaneously, both on our side and the doctors’ side, there became a clear understanding that we all have one goal. It is important that their patient and our client go to the medical facility and start getting treatment.”

Both during COVID-19 and after, one thing is certain—peer consultants will continue to play a vital role in bringing HIV services to people living with HIV in Kyrgyzstan. 

During the COVID-19 crisis, activists and community organizations from across eastern Europe and central Asia are continuing to provide vital HIV prevention, treatment, care and support services.

To map that support, an interactive platform, the Community Initiates Map, has been launched. The website shows how communities are supporting people living with HIV and saving lives during the COVID-19 outbreak in the region, with stories about the services that community organizations are providing. People can learn from the examples of the services developed for key populations and people living with HIV and the impact that they are having on the HIV epidemic and on people’s lives. The map is constantly being updated and people can share their stories on the site.

Vera Brezhneva, UNAIDS Goodwill Ambassador for Eastern Europe and Central Asia, thanked activists for their commitment during the COVID-19 outbreak. “Thank you to every one of you, from all of us. It is in our power to remember and take action. I am with you!” she said.

The experience in eastern Europe and central Asia in the fight against COVID-19 shows that investments made in civil society are good investments. “Communities and nongovernmental organizations have not only come to the forefront of the fight against the new threat, but also in collaboration with medical practitioners and governments continue to provide HIV and tuberculosis services,” said Andrei Klepikov, Executive Director of the Alliance for Public Health.

Nurali Amanzholov, the President of the Central Asian Association of People Living with HIV, said that the coronavirus outbreak and lockdowns had resulted in some people having difficulties in accessing antiretroviral therapy and opioid substitution therapy, and that many people had lost their incomes. “But this situation is also an exam, a test of the strength of our community. And our strength was always in solidarity, the ability to assert our rights, to seek the right solution together,” he said.

Lyubov Vorontsova, of the Central Asian Association of People Living with HIV, said that women living with HIV, especially those in key populations, faced increased gender-based violence and limited access to protection and social services owing to the closure of crisis centres. “We must keep our unity now, so that after the end of the state of emergency, the needs of women remain a priority for the state and civil society,” she said.

“The nearly 40 years of experience in the response to HIV shows that civil society organizations, including communities of people living with HIV, play a crucial role. Today, it is clear that the role of community organizations in emergencies is vital. Countries in the region must recognize those organizations as partners and providers of services for the responses to both HIV and COVID-19,” said Alexander Goliusov, Director, a.i., UNAIDS Regional Support Team for Eastern Europe and Central Asia.

The website was developed by the Alliance for Public Health and the Central Asian Association of People Living with HIV and supported by the UNAIDS Regional Support Team for Eastern Europe and Central Asia.

She is sitting opposite, dressed in a lab coat, and you know that with her you are in safe hands. Her kind eyes convey empathy. Malikakhon Kurbanova, known to all who know her as Malika, has been a nurse at the Kyzyl-Kiya family medical centre in Kyrgyzstan for almost 20 years.

Part of one of 10 pilot multidisciplinary teams specializing in infectious diseases in the country, she has been working with people living with HIV for many years. The multidisciplinary teams were formed by UNAIDS in 2013 and include a specialist in infectious diseases or a family doctor, a nurse and a peer consultant. The teams aim to improve the quality of medical and social services for people living with HIV and their families. During the COVID-19 outbreak they are receiving extra financial help from a Russian technical assistance programme.

Like many health-care workers, Malika has been caught up in the fight against COVID-19. UNAIDS met her recently in her office in the clinic, adjacent to a blossoming apple orchard, and spoke to her about her background and work.

Why did you decide to become a nurse?

When I was a child, I was quite often sick. My mother and I spent a lot of time in hospitals. I always admired the women who wore lab coats and who knew how to inject me painlessly. I knew then that I would become a nurse and help people. When I graduated from school in 1986, I entered the Kyzyl-Kiya medical college and after that, in 1989, I went to work in the health unit in a construction materials plant. That is how my story began. In the beginning of the 2000s the reform of primary health care started and family medical centres were created. I came to work as a nurse and soon joined the infectious diseases unit, where I still work.

You have been working in the COVID-19 response since the very start of the epidemic in the country. Were you frightened?

We do house-to-house visits, helping people with acute respiratory infections. We are human, so of course it was scary—I was afraid about infecting my family.

It is frightening when you are fighting an unknown virus. In the beginning, I did not know what I should tell patients. At the beginning of the pandemic, many people did not believe the truth about COVID-19; some of them accused us of trying to infect them. But over time, people realized that the virus was real, which greatly helped our work.

You work as a nurse in a multidisciplinary team for people living with HIV. How has your work changed since the COVID-19 outbreak started?

To avoid people running out of their medicine and to reduce their possible exposure to people with COVID-19, we are now distributing three-month supplies of antiretroviral therapy, when before we gave out one-month supplies.

We also focus on psychosocial support for people living with HIV. People need mutual support. Our peer consultant calls patients every day and holds online self-help groups via WhatsApp. Thanks to the financial support given to the project, the transport costs of visiting clients and monitoring their adherence to antiretroviral therapy is covered. The most vulnerable people living with HIV have been receiving food packages since April.

What is the hardest part of your work?

We’ve always had difficulties and they are likely to continue, that is the nature of our work! Sometimes I feel like leaving it at behind, but then I realize that this is my life—I am a nurse. It gives me strength when I see that my actions for my patients bring results and people get better.

Homeless people have difficulty accessing health-care services at the best of times, but the COVID-19 pandemic has curtailed access even more. Stigma and discrimination and the conditions they live in make homeless people particularly vulnerable not only to COVID-19 but also tuberculosis, HIV, hepatitis and other diseases.

“Before the COVID-19 pandemic there were about 11 shelters in Minsk where people could get clean clothes, wash themselves, have food and stay for a night. Now only three of them remain open,” said Karina Radchenko, a volunteer from Street Medicine, the country's first volunteer network to treat the homeless. “We know that some of them are living with HIV, but because they don’t have proper identification and residence registration they can’t get free treatment. This is why we need to keep providing support to the homeless, especially now.”

Launched by Street Medicine, UNAIDS, the Positive Movement—a Minsk-based nongovernmental organization that provides HIV services—and the Ministry of Health of Belarus, a new initiative is providing HIV testing and support to the homeless during the COVID-19 pandemic.

Working on the streets, the volunteers distribute condoms, hygiene packs and over-the-counter medicines and provide HIV testing and counselling together with first aid, such as wound treatment and bandage application. The first phase of the initiative will see at least 200 homeless people in Minsk and beyond being tested for HIV and will collect information on their HIV prevention needs and the barriers they face in accessing HIV treatment and other health services.

“Homeless people very often don’t have identification, and this complicates a formal recognition of their HIV status and their access to HIV treatment,” said Vera Ilyenkova, the UNAIDS Country Manager for Belarus. “One of the goals of this initiative is to help people who test positive for HIV to get connected to health facilities so they can get treatment and proper documents from the authorities.”

The network of the Russian Federation’s more than 100 AIDS prevention and control centres, established in 1989 to respond to HIV, has been mobilized to support the country’s fight against COVID-19.

Each of the centres, which specialize in HIV surveillance, prevention, testing and treatment, has high-technology laboratory equipment, highly qualified health staff, including infectious disease specialists and epidemiologists, and expertise in epidemiological surveillance and contact tracing. Those centres are now using their technology and expertise on HIV testing and diagnosis to scale-up testing for COVID-19.

Public health experts at the AIDS centres are also supporting epidemiological surveillance and contact tracing, using the approaches developed for HIV. Many of their doctors and nurses have been seconded to medical teams dedicated to providing care for people with COVID-19.

“Many AIDS centres across the country have repurposed their laboratories to also diagnose coronavirus, but provision of quality medical care for people living with HIV continues,” said Natalia Ladnaia, Senior Researcher at the Central Research Institute of Epidemiology of Rospotrebnadzor, Russian Federal AIDS Centre.

In order to ensure the continuity of HIV services, many AIDS centres are working closely with community organizations to provide online counselling, deliver antiretroviral therapy to people living with HIV to their homes and address mental health challenges, which have grown since the COVID-19 pandemic began. Community activists from Novosibirsk representing the Ostrov and Humanitarian Project nongovernmental organizations, in collaboration with the regional AIDS centre, are delivering antiretroviral medicines to people living with HIV who are not able to collect their medicine from the AIDS centre.

Even some HIV testing services are moving online. Owing to quarantine restrictions, mobile laboratories cannot travel, so the Humanitarian Project organized remote testing for key populations in Siberia. “We are working with representatives of key populations and the regional Ministry of Health,” said Denis Kamaldinov, the head the Humanitarian Project. The initiative is providing online support and counselling for people who are at risk of HIV. Since March 2020, online and telephone-based counselling related to HIV and the health of people who use drugs and other key populations has intensified. “Our counsellors are communicating with clients by phone, social media and instant messaging,” he added. In order to receive an HIV self-test kit, a client only needs to complete an online application on the organization’s website.

The Deputy Prime Minister of the Russian Federation, Tatiana Golikova, has called for nongovernmental organizations working with key populations and people living with HIV to be supported during the COVID-19 pandemic. The regions that have introduced COVID-19 lockdowns have been advised to allow nongovernmental organizations working on social services, including the AIDS response, to continue their work, with their employees having freedom of movement and being supplied with personal protective equipment.

"The unique value of the AIDS centres is demonstrated by their quick and professional response to COVID-19. We are seeing this leadership coming from AIDS centres across the region. With the strategic involvement of AIDS centres and their partners, the COVID-19 response in our region will be more effective and the risk of progress in the AIDS response being rolled back will be mitigated,” said Alexander Goliusov, Director, a.i., of the UNAIDS Regional Support Team for Eastern Europe and Central Asia.

Like most other countries, COVID-19 has not bypassed Kyrgyzstan—cases have been seen in the capital, Bishkek, and in almost all other major cities and provinces in the country.

In order to respond to the pandemic, a state of emergency was introduced on 25 March in Bishkek, Osh, Jalal-Abad and three districts, which restricts people to their home from 20:00 to 07:00 and allows people to leave their residence during the day only for a few specified reasons.

Like everyone else, people living with HIV in the country—UNAIDS estimates that there are 8500 people living with HIV in Kyrgyzstan—have faced a variety of challenges, including loss of earnings and difficulties in feeding their families.

In the small town of Karabalta, in the north of Kyrgyzstan, the HIV community organizations Believe in Yourself and the Country Network of Women Living with HIV work to promote the rights of people living with HIV. In the time of COVID-19, however, their services are even more in need.

Umid Shukurov, the Director of Believe in Yourself, explained that since the lockdown in Kyrgyzstan was announced, people living with HIV have got in contact with the organization in greater numbers. Access to food is a major concern for many. “Many people call us in despair, women cry and ask for help. Of course, we help in every way possible, but our resources are limited. When we, together with the Country Network of Women Living with HIV, compiled a list, we realized that 12 women living in our small town are in a distressed situation. Some of them have recently become mothers or are raising their children alone. Yesterday, we distributed food packages and some women could not believe that someone had reached them and brought them some food. The asked me, “Is it real that someone has heard us?”’’

Baktygul Shukurova, the Director of the Country Network of Women Living with HIV, knew that the network would face various problems after it was set up, but never thought that the problems would be of this magnitude. “Our task is to keep people on antiretroviral therapy. I have been through difficult situations in life myself and I know how difficult it can be when you simply have nothing to feed your children with. Only a person who has been through all this can understand the needs of communities. When you and your children have nothing to eat, you don’t care about the medication.”

Access to antiretroviral therapy is being ensured in the country by the provision of mulitimonth dispensing of medicines. During the COVID-19 pandemic, the national AIDS centre in Kyrgyzstan will be providing three-month supplies of antiretroviral therapy to all people living with HIV who are on treatment.

The UNAIDS Country Office in Kyrgyzstan, with the support of a Russian technical assistance programme, is organizing the delivery of food packages, which will supplement other social assistance available for people living with HIV, to 130 families of people living with HIV who have been the most affected by their loss of earnings. Apart from the food, the packages also contain colouring books, marker pens and watercolour sets for the children of people living with HIV, to help them get through the lockdown.

“We hope that this small help will go some way to enabling people living with HIV to remain on treatment,” said Meerim Sarybaeva, the UNAIDS Country Manager for Kyrgyzstan.

From 17 March, following the government’s declaration of a state of emergency in response to the COVID-19 pandemic, around 800 people living with HIV in the Republic of Moldova have been receiving antiretroviral therapy at home for free.

A team of social workers and people from the four regional centres for people living with HIV are ensuring the timely delivery of the medicines and are giving information on protection against COVID-19. The social workers, trained by the World Health Organization, explain how to prevent the transmission of the coronavirus, identify its symptoms and take the necessary action in the event that people contract COVID-19. 

The emergency measures put in place by the government will initially last until 15 May and include limitations on people leaving their homes except for going to work, buying medicines and food and walking their pets.

AIDS activists agree that the decision will help to avoid the risks encountered by people living with HIV associated with travelling by public transport and going to health centres to get their medication. Most importantly, it will help to avoid interruption of HIV treatment.

“We had to find the most effective solution to this problem, and we are proud that the representatives of the national AIDS programme found a solution,” said Ruslan Poverga, General Director of the Positive Initiative. “The medical sector, social services and nongovernmental organizations are doing everything possible to provide people living with HIV with access to treatment and reduce their risk of coronavirus disease.”

In the Republic of Moldova, more than 6000 people living with HIV are receiving HIV treatment, which they usually get from eight treatment facilities around the country, including prisons. In order to provide the medicines in people’s homes, the National HIV Programme Management Unit developed an algorithm to assess the risk of people living with HIV not being able to access their medicines, taking into account distance from the treatment facilities.

Identifying an efficient solution and obtaining all necessary political support and approval, as well as designing the algorithm and starting the implementation of the programme within one week of work, was made possible owing to the leadership of the Ministry of Health, Labour and Social Protection, the National HIV Programme Management Unit and the Positive Initiative. UNAIDS and the World Health Organization bureau in the Republic of Moldova provided guidance and technical and financial support to ensure the efficient implementation of the initiative.

“The delivery of antiretroviral medicines to people living with HIV in remote, rural and other areas of the Republic of Moldova, where there are no HIV treatment centres, through the involvement of nongovernmental organizations and regional centres for people living with HIV, is an amazing solidarity and mobilization effort by all partners,” said Svetlana Plamadeala, UNAIDS Country Manager for the Republic of Moldova.

When Tahmina Khaidarova was married it was in accordance with her family’s cultural traditions—her parents chose her cousin to be her husband. She rarely saw her husband, who worked in another country, returning home to Tajikistan only for short visits once a year. When her little daughter fell seriously ill and died, she hoped to get pregnant again to ease the pain of her loss. During a medical examination, she was diagnosed with HIV. Soon her husband died of an AIDS-related illness.

Today, Ms Khaidarova is the Director of the Tajikistan Network of Women Living with HIV (TNW Plus), which educates women on HIV, protects their rights and breaks the vicious cycle of stigma against women living with HIV. She overcame her self-stigma and became a leader in fighting for the rights of women living with HIV in Tajikistan.

Ms Khaidarova explained that women who are aware of the risk of contracting HIV from their migrant husbands often can’t talk to them about using a condom. “I understand how serious the problem is, but I cannot ask my husband to use a condom, he will not understand,” one woman told Ms Khaidarova.

Women living with HIV in Tajikistan tell stories of discrimination. They can be driven from their home by their husband’s relatives and may be prevented from seeking medical services, including antiretroviral therapy and treatment for tuberculosis. They are also often subjected to domestic violence, with their husbands prohibiting their wives from seeking treatment or being told to leave their home, along with their children. After their husband’s death, they can endure violence and abuse by their husband’s family, especially in rural areas.

When women living with HIV seek help, they can face a new challenge—stigma and discrimination from health-care workers. Many women are told that they cannot have children in the future, or that they should only marry a man living with HIV or that they should not marry and have sex.

“Stigma and discrimination against women living with HIV can have devastating consequences. It can stop them accessing the health services they need, tear families apart and profoundly affect their ability to live a normal life,” said Ms Khaidarova. “Stigma and discrimination must be stopped, and stopped now!”

The need to counter stigma and discrimination against women in general and against women living with HIV has been recognized by the government. Women were included as one of the priorities in the national development strategy. The new national AIDS programme for 2021–2025 includes a separate block on human rights and reducing stigma and discrimination against women living with HIV.

To bring attention to the issue of HIV-related discrimination in the family, in society and, too often, in medical settings, Ms Khaidarova took part in the #InSpiteOff social media campaign. Featuring the right of women living with HIV in eastern Europe and central Asia to live with dignity and respect, the #InSpiteOf campaign featured Instagram stories showing different aspects of women living with HIV and challenged the stereotypes and myths that surround the virus.

A common feature of all the women featured in the campaign is that they were supported at a critical time in their lives by their loved ones, women’s organizations or communities and are now not only living with HIV and challenging society’s stereotypes, but helping others.

“I told my story in order to help those women who face the same challenges today. I strongly believe that we all together can break the vicious cycle of stigma against women living with HIV in Tajikistan. We have to cope with our own fear in order to fight stigma and discrimination in society,” said Ms Khaidarova.