The Council adopted a new and enhanced health and social programme for the years 2004 – 2007 on the 3rd of October 2003 with emphasis on the situation in the Russian part of the Barents region. The priority areas identified by the WG, chaired by Finland and the Republic of Karelia, were as follows:
• Prevention and control of communicable diseases
• Prevention of lifestyle related health and social problems, and promotion of healthy lifestyles
• Development and integration of primary health care and social services.
It was suggested that the priority for the BEAC in the field of communicable disease control should be HIV/AIDS during the first years of the programme. An ad hoc group was created for preparing a multilateral project on HIV/AIDS. The group proposed to ask STAKES (National Research and Development Centre for Welfare and Health, Finland) to conduct this work. STAKES nominated Dr. Zaza Tsereteli to function as a consultant and to continue the preparations of the project.
It was emphasized from the beginning that the preparation and implementation of the future Barents HIV/AIDS Program should be the responsibility of the local authorities in the Russian regions. It was agreed that the regions should define their own needs and set up their own goals. Many programmes or projects were introduced in Russia during the last several years, but not many were successful or sustainable for longer than the project periods. Such programmes or projects are shown to have a positive impact on the situation only if the Russian authorities participate in their preparation and the local needs are taken into account from the very beginning. What is most important, they should be responsible for the implementation.
During the first six months of the programme preparation more than 50 meetings were arranged and more than 100 persons were interviewed. The processes proceeded from general to detailed discussions, starting with problem identification and assessment of needs. In the middle of the preparation process, a two-day working seminar was conducted in Petrozavodsk where a parallel meeting of officials and HIV/AIDS experts took place. More than 30 HIV/AIDS experts from the Russian regions, Finland, Norway, Sweden, the World Health Organization and other relevant international bodies took part in the seminar financed by the Norwegian government. The seminar concluded that the HIV/AIDS epidemic is still spreading in the Barents region and that a comprehensive response to the HIV/AIDS situation is lacking. Interventions to improve the health infrastructure and to influence individual and social norms are still not effective and efficient. As a result it was agreed that the main aim of the new HIV/AIDS Programme in the Barents region will be to strengthen the national capacity to respond to the epidemic.
What does the Barents HIV/AIDS Programme address? The HIV/AIDS component of the programme includes six key focus areas for multisectoral and complementary interventions. The programme advocates catalytic activities to provide new momentum and strengthen intervention measures previously implemented. Despite a globally unfavourable context, the programme requires evidence of the government’s continued interest in the priority areas of public health.
The six objectives of the programme are to:
- update the existing legislation to assure effective policies for control of the HIV epidemic
- improve the technical response capacity for project planning and implementation
- implement comprehensive and realistic prevention and surveillance activities
-assure affordability and accessibility of antiretroviral (ARV) treatment related to individual needs within the public health system
- implement programmes ensuring respect for human rights, including people living with HIV/AIDS (PLWHAs)
- establish coordination between HIV/AIDS services and primary health care, educational, penitentiary and social services.
The programme focuses on interventions in a number of problem sectors. The programme aims at providing a greater number of PLWHA with better and more organized management of their own health including access to treatment, patient follow-up and control of ARV treatment compliance.
Vulnerable populations will also receive more and better assistance to make preventive behaviour part of their life irrespective of living conditions. One area of activity involves behavioursurveys and studies among vulnerable sub-populations including injecting drug users (IDUs), sex workers, prisoners, men who have sex with men (MSM) and young people. Based on the recommendations of an external review, behavioural surveillance of vulnerable sub-populations is identified as the next priority for the national surveillance system.
There is insufficient knowledge about the evolution of the disease. This is caused by deficiencies in the notification system, inadequacies in keeping secondary serosurveillance survey records and failure to conduct behavioural surveillance. This situation will be remedied through a reorganization of the system and enforcement of procedures.
Legislation should not prevent effective, evidence-based prevention strategies. Rather, the laws should facilitate preventive activities in all population groups including people who are particularly vulnerable to the infection and may act as a gate through which the virus may enter the general population. Legislation should also promote the participation of the entire civil society in the fight against HIV. The programme aims at supporting development of legislation that enables the implementation of evidence-based prevention strategies among vulnerable groups such as drug users, other socially excluded groups, sexual minorities etc.
Overcrowded prisons with infected inmates, poor hygiene and sanitation are important risk factors contributing to the spread of communicable diseases in the region. The risk of HIV infection is higher for prison inmates than for the general population. Prisons might be a unique site for successful preventive work regarding HIV and drug abuse.The promotion of voluntary counselling and testing for prisoners and the provision of training for staff and prisoners regarding HIV prevention will be included in the programme activities.
Every activity has been modelled on experience gained and lessons learned from within the Russian Federation. In addition, the activities incorporate good practice from the other countries, for example the design of harm reduction and information education and communication (IEC) programmes. Technically, many activities may be seen as a scaling-up of existing projects in Russia. However, given the many challenges of such a sizeable scaling-up process, many of the activities will be new. For example, international best practices indicate that non-governmental organizations (NGOs) must play a critical role in interventions concerning vulnerable populations. Despite the fact that there are local NGOs in Russia currently working with vulnerable populations, fully implementing this approach will require wide-ranging and groundbreaking collaboration with the country’s NGO sector.
Another key area that is both a comprehensive and realistic part of the prevention and surveillance component is the strengthening of needle exchange programmes throughout the region. These will focus on providing IDUs with sterile needles and associated consumables thus reducing the need to share injecting equipment and intravenous solutions. The needle exchange activities will be supported by an expansion of low threshold support centres (LTSC) and outreach services for IDUs. All activities will be implemented with the active involvement of IDUs. In general, this broad-based approach to harm reduction puts Russia on the leading edge. Given the critical link between IDUs and HIV/AIDS it is necessary to take a progressive approach to reduce vulnerability of IDUs and prevent the spread of HIV among IDUs and the population in general.
The first and second objectives address the development and implementation of policies to ensure an environment in the country that facilitates work with vulnerable populations. The activities include education and advocacy campaigns targeting policy makers and opinion leaders in Russia, training for journalists on HIV/AIDS and improvements in surveillance policy and practice. Different government organizations, NGOs and other partners, each of which will be required to have relevant knowledge and skills, will implement activities across all the objectives. The implementing partners will have access to domestic and international technical assistance to ensure that the interventions are effective.
The third objective concerns effective prevention programmes focusing on the needs of vulnerable population. The activities include harm reduction initiatives for IDUs, outreach and peer education programs with sex workers and MSM, IEC and condom distribution programmes in prisons, school and community-based IEC-BCC programmes for young people and improved services for sexually transmittedinfections (STI).
Activities related to the fourth objective, access to treatment for PLWHA, include broad-based care and treatment services (e.g. ARV, treatment for opportunistic infections, psychosocial support and palliative care) and maternal care and treatment centre (MCTC). Focus will be on developing a network of diagnostic laboratories to enable monitoring of disease progression, evaluation of treatment success and resistance testing in the case of treatment failure. The supporting role of the NGOs and the communities concerning home-based care and clinical management of infected persons should be strengthened.
The fifth objective is to establish respect for human rights, including PLWHAs. The activities under this heading are based on recognition of the fact that an effective response to HIV/AIDS demands an understanding of the link between HIV/AIDS and human rights. Provision of training and technical assistance to staff and other health and humanitarian service providers for implementing the principles of confidentiality, non-discrimination and cultural diversity will be supported. Emphasizing that HIV-related discrimination is illegal is an important part of the current programme.
The Barents HIV/AIDS Programme is taking a multisectoral approach in recognition of the fact that the HIV/AIDS epidemic has an impact on every sector and all development programmes.. Coordination is a main tool for the implementation of all planned activities. Consensus building among representatives of different sectors at the regional level will be organized to reach decisions concerning improvement of the infrastructure, spectrum of services, coordination, referral system, quality control systems in health care, and the social and penitentiary sector with regards to HIV/AIDS policy. Representatives from the educational, primary health care, penitentiary and social sectors will be invited and actively involved in the implementation of different activities.
The programme is supporting the establishment of a monitoring and evaluation (M&E) system to perform the critical task of monitoring and evaluating the programme implementation. The system will provide valuable information for the programme management and for other stakeholders and external parties. It will allow project managers to assess whether existing projects and interventions are sufficient and to identify challenges that may deter successful outcomes.
A multinational Steering Committee (SC) chaired by Norway has been established for the programme. The Murmansk Health Committee has taken the position of Vice Chairman of the SC. This committee will meet 2-3 times a year. Members of the Steering Committee are appointed from countries or regions in the Barents region. The meetings and the reports are made available to other interested parties. Donors and international organizations etc. participate as observers. STAKES and the Programme Co-ordinator (PC) operating under STAKES are responsible for the implementation of the programme.
The Barents HIV/AIDS Programme is starting with the implementation of a project financed by Government of Finland. The project will establish preventive services accessible to high-riskand vulnerable groups. The representatives of the Murmansk Health Committee have expressed their commitment to accelerate the initiation of the first tangible sub-project. The activities of this project, which will be implemented in collaboration with local specialists from the primary health care sector, social workers and others, will be conducted through LTSCs that serve both IDUs and associated populations. Several other projects are in the pipeline and the Barents HIV/AIDS Programme will continue to act as an umbrella for different projects in the Barents region.