HIV/AIDS and TB in Central Asia

  CENTRAL ASIA ISSUE BRIEF

The World Bank
Updated as of February 2005

Although the number of reported cases of Human Immunodeficiency Virus (HIV) in the five countries of Central Asia - Kazakhstan, Kyrgyz Republic, Tajikistan, Turkmenistan and Uzbekistan - is still low, evidence indicates that HIV is spreading rapidly. It appears to be driven largely by fast-rising intravenous drug use (IDU) in Central Asia, and is compounded by epidemics of tuberculosis (TB) and sexually transmitted infections (STIs).

Central Asia has witnessed a dramatic increase in the numbers and rates of infection over the past four years. Officially reported cases jumped from about 500 in 2000 to over 8,000 in 2004 – a 1,600 percent increase. Unreported cases are thought to be much larger: the Centers for Disease Control and Prevention in Central Asia estimate the number of people living with HIV/AIDS in these countries at some 90,000.

According to UNAIDS, HIV prevalence remains very low (less than 0.3 percent) in most of Central Asia and the Caucasus. However, in Uzbekistan and Kazakhstan, the epidemics are growing rapidly and are concentrated among young people who inject drugs and/or engage in commercial sex. In Uzbekistan, almost 91 percent of all of the country’s 2,500 reported cases of HIV were diagnosed between 2001 and mid-2003, with commercial sex appearing to play a large role.

The Kyrgyz Republic’s much smaller epidemic is fueled mainly by injecting drug use and is concentrated around the city of Osh.

Although currently concentrated among injecting drug users, prison inmates, and commercial sex workers, the epidemic can easily spread to so-called bridge populations. These are typically the sex partners of injecting drug users and the clients of commercial sex workers. Eventually, the epidemic may spread to the general population. Unchecked, the epidemic’s impact at the household level will be catastrophic, with major consequences for national health expenditures and economic growth.

Drivers of the epidemic

Injecting drug use. A major cause for concern are the drug trafficking routes that pass through Central Asia, which have led to a surge in drug use since 2001. Experts estimate that there may be more than 500,000 drug users in Central Asia, many of whom share needles, placing them at high risk of contracting HIV/AIDS.

Tuberculosis. TB is the main opportunistic disease for HIV/AIDS and is a major of people with HIV/AIDS. The TB situation is considered critical in Kazakhstan, Tajikistan, Turkmenistan, and Uzbekistan. TB-HIV co-infection, when it occurs, undermines treatment and care, reduces survival substantially, and increases healthcare costs. HIV also drives the TB epidemic, particularly in areas where the prevalence of both diseases is high.

Fast growth among young people. Some 40 percent of the region’s population is young and HIV/AIDS is spreading most rapidly among them. Adolescents and young adults account for most reported cases among injecting drug users and the age at which young people start injecting drugs is falling. Moreover, they face high levels of unemployment and, with jobs in short supply, many are at special risk of joining groups of highly vulnerable people by resorting to injecting drug use and regular or occasional unprotected sex.

Increased trafficking of women, commercial sex work, and STIs. The proportion of HIV/AIDS cases attributed to heterosexual transmission is growing, with UNAIDS reporting a narrowing of the male-female ratio of newly detected  HIV/AIDS cases from 4:1 to 2:1, indicating that women are increasingly at risk.

Migration increases the risk of spread. Porous borders and easing of travel restrictions, combined grinding poverty, have increased mobility from rural to urban areas, both within countries and within the region. Central Asia ’s large migrant population increases the risk of the spread of HIV to the general population. Truck drivers, mariners, the homeless, refugees, migrant workers, and trafficked women are among those who are highly vulnerable.

Lack of capacity in public health system. The ability of the public health system to trace, diagnose, and treat patients with infections has significantly deteriorated since the collapse of the Soviet Union. Furthermore, HIV/AIDS STI and TB services are generally provided through vertical program structures with little or no coordination.

Actions by Governments, NGOs and partner organizations

Governments, NGOs and partner organizations have initiated appropriate early action to avoid a major epidemic: the Governments of Kazakhstan, Kyrgyz Republic, Tajikistan and Uzbekistan have have started implementing HIV/AIDS Strategies. A Regional AIDS Strategy prepared by UNAIDS in collaboration with Central Asian countries provided the framework for a series of country-specific plans.  Kazakhstan, Kyrgyz Republic, Tajikistan and Uzbekistan applied for, and have been granted, funding from the Global Fund Against AIDS, TB and Malaria (GFATM).

In June 2004, the Governments of Kazakhstan, Kyrgyz Republic, Tajikistan and Uzbekistan signed a Memorandum of Understanding committing to regional cooperation to prevent HIV/AIDS and to prepare a Regional HIV/AIDS Project to be supported by the World Bank.  They also signed a Japan Policy and Human Resources Development Fund Grant Agreement for project preparation and are actively participating in Regional Meetings being organized by UNAIDS, DFID and the World Bank to agree on project design (see more under World Bank role below).

World Bank's Role

A proposed $32.16 million Central Asia AIDS Control Project covering four countries - Kazakhstan, Kyrgyz Republic, Tajikistan and Uzbekistan - is under preparation.  Scheduled for consideration by the World Bank’s Board of Executive Director’s on March 15, 2005, the project will help minimize the potential negative human and economic impact of a generalized epidemic.  It would complement country-specific programs and projects.

Funding. The International Development Association (the World Bank’s concessional lending window) and DfID (the UK Department for International Development) are expected to provide cofinancing in the form of grants totalling $26.8 million, which will be disbursed to the Central Asia Cooperation Organization, or CACO.

Project goals.  Objectives under the project are to: (i) reduce the growth rate of the HIV/AIDS epidemic in Central Asia in the period 2005-10; (ii) establish a sustainable mechanism in Central Asia - a Regional AIDS Fund - that will serve as a vehicle for financing HIV/AIDS prevention and control activities in the Region beyond the end of the project; and (iii) contribute to better regional cooperation in Central Asia, and effective inter-sectoral collaboration between the public sector, non-governmental organizations (NGOs), and the private sector on HIV/AIDS control.    The regional project would establish a legal environment that allows for prevention work with highly vulnerable groups, including prisoners, sex workers and drug users.

In Uzbekistan, the Health II project, which has an HIV/AIDS component, was approved this year.  In the Kyrgyz Republic, the World Bank is helping to implement a Health II Project and recently completed a nationwide attitudinal survey of adults to test attitudes and awareness about AIDS. In Turkmenistan, the Bank is continuing to track trends in drug use, HIV/AIDS, STIs and TB, and is following up the work carried out by the Government and partner organizations to prevent and control these diseases.

Studies. The Bank has developed HIV/AIDS and TB Country Profiles for all countries in Central Asia and has completed a Central Asia AIDS study. A separate but related Central Asia TB study is also under way. Additional studies focus on identifying strategies for early and effective intervention to control the epidemic at the national and regional levels. In Kazakhstan, in-depth reviews of HIV/AIDS and TB programs, including expenditure reviews, have been carried out jointly by the governments and the Bank.

Next steps

Improved surveillance. By initiating or improving second-generation surveillance, which includes epidemiological and behavioral monitoring, governments in the region would be better equipped to assess the epidemic and plan effective interventions. Such second generation surveillance, which is endorsed by WHO and UNAIDS, is becoming widely adopted around the world.

Expanding work with vulnerable groups. Prevention efforts targeted at highly vulnerable groups should be increased. These groups include injecting drug users, commercial sex workers, men who have sex with men, and young people, especially those who are unemployed or institutionalized.

Scaling up funding to support expanded HIV/AIDS, Drug Abuse Treatment, and STI Programs. Funding available from the public budgets to prevent and treat HIV/AIDS is limited in all countries, although grants from the GFATM have been awarded to Kazakhstan, Kyrgyz Republic, Uzbekistan and Tajikistan. More than $15 million is immediately necessary to reach the estimated 500,000 IDUs in Central Asia with a package of services including disposable syringes, condoms, and education about the transmission of the infection.  However, given the large numbers and inaccessibility of IDUs, this figure might be a gross underestimation of needs, especially with respect to the supply of needles and the resources necessary to distribute them.

Additional efforts are necessary to expand substitution treatment programs, particularly with respect to incorporating these programs into primary care health delivery systems.  Current pilot programs reach only a few thousand IDUs.

Scaling up will require enormous additional resources. According to recent estimates, about US$ 1 billion would be necessary for HIV/AIDS prevention and treatment in Central Asia in the period 2004-2007.