Getting services to vulnerable communities
As part of a programme to reach vulnerable communities with HIV prevention, treatment and care, community centres were established for people who inject drugs. These offered an innovative range of services including HIV prevention, day care for children, social activities and help with day-to-day issues such as transport, nutrition, employment and legal problems.
The Alliance worked closely with the National AIDS Centre and regional AIDS centres to develop national HIV treatment standards and training medical staff, while supporting NGOs to take on adherence support and peer counselling.
This process helped form vital links between AIDS centres and people in need of treatment. Traditionally, people vulnerable to HIV, such as people who inject drugs are very wary of official health services, fearing discrimination and disclosure of drug use and HIV status. The involvement of locally trusted NGOs helped to build confidence in these services.
This approach has increased the range and scale of HIV services. Interventions recommended by the WHO for HIV prevention, treatment and care among people who use drugs are now being provided in all 27 regions of Ukraine. A comprehensive package of services was possible because of a referral system developed through close work with health service providers and public agencies.
Working through civil society organisations is essential to reach drug users, assess what drug users need to prevent HIV transmission and to make sure that programmes address changing needs and patterns of drug use.
Community involvement is essential in order to develop and scale-up services. Trust with the community can take years but once established means that programmes can be launched and implemented successfully and can be sustained over time.
The Alliance aims to keep a balance between public health approaches and human rights approaches to programming, working on the principle that people will use services if the services provide them with what they need.
Advocacy removes barriers to substitution maintenance therapy
Substitution maintenance therapy (SMT) is an effective way of improving adherence to ART among people living with HIV who are injecting drugs, as well as preventing HIV among people who inject drugs. It was therefore identified as an essential part of ART scale up alongside HIV prevention activities.
Availability of SMT in Ukraine was limited to a UNDP funding six month pilot project using substitution therapy medication, buprenorphine.
SMT proved extremely challenging for many state agencies to accept. Although it formed part of the public health strategy, few people outside the international HIV community in Ukraine were committed to it. In addition, medical professionals dealing with drug dependency were reluctant to take on additional workloads and were concerned about the impact of SMT on existing treatment for drug dependence.
The Alliance developed and led an advocacy campaign involving PLHA Network, the Clinton Foundation, the Open Society Institute, WHO and Ukrainian Institute of Public Health Policy, UNAIDS and UN Office on Drugs and Crime.
Campaign case study
There were two phases to the campaign. The first was to introduce SMT to demonstrate its effectiveness in the Ukraine context. Initial SMT was based on buprenorphine as this was already a registered drug in the country and Ukrainian drug treatment specialists were familiar with it. The second phase focused on assisting scale up through the introduction of methadone – a less expensive drug more suited for larger-scale provision of SMT.
Through meetings and national conferences, officials were introduced to international experience of implementing SMT. In 2007 the President of Ukraine strongly criticised the government for its lack of fulfilment on its commitments to the Global Fund, particularly with regard to implementing methadone-based SMT.
Following recommendations from those involved in the campaign a Presidential Decree was issued requiring the elimination of barriers to the scale up of methadone based SMT. It also established the Presidential Council for AIDS, TB and Drug Addiction.
The Alliance and partners worked with state agencies at the highest level to secure this commitment. Following continual pressure and lobbying in May 2008 methadone-based SMT was introduced, marking the culmination of a united advocacy campaign of all organisations working on HIV and AIDS in Ukraine.
However its implementation was slowed down by sustained opposition to SMT within the state sector but when the Global Fund gave an unacceptable rating for the Ukraine grant appraisal on this issue, the Minister of Health signed an order that made way for the scaling up of implementation.
The national state programme now includes SMT with methadone. Alliance Ukraine expanded availability of SMT from six to 26 regions. A 12-month monitoring exercise conducted by Alliance Ukraine, WHO and the Ukrainian Institute of Public health policy in 2008 demonstrated that SMT is a proven method for supporting people living with HIV who are injecting drugs, through HIV treatment programmes.
Traditionally, people vulnerable to HIV, such as people who inject drugs are very wary of official health services