HIV/AIDS in Central and Eastern Europe
March 23, 2004 On March 23 a group of CSO representatives from Moldova, Russian Federation and groups being members of the AIDS Action Europe Network, held a video discussion on the topic of HIV/AIDS in Central and Eastern Europe, sharing their experiences and learning about the Bank's work in that area in the region.
MEETING NOTES (1) John Garrison (Washington)
John (Civil Society Team) began the video conference by introducing himself and going to each site so the facilitators could introduce the participants. John explained that this session was part of a series of Global Video Links the Bank has sponsored with Civil Society Organizations (CSOs) to promote dialogue and consultation on a number of important development topics. A total of seven videoconferences involving CSOs in 21 countries have been held in the past two years. John informed participants that this video conference would focus on HIV/AIDS in Central and Eastern Europe. It comes in the heels of the European Union Ministerial Conference "Breaking the Barriers-Partnership to fight HIV/AIDS in Europe and Central Asia", 23 to 24 February 2004, Dublin, Ireland. It is also being held to coincide with the launch of the pan-European group AIDS Action Europe which is a network of AIDS CSOs. Finally, John explained that the format for the VC would consist of several 10 - 15 minute presentations from Bank staff in Washington (United States) and Ankara (Turkey), and CSO representatives based in Brussels (Belgium), Moscow (Russia), and Chisinau (Moldova). These would be followed by a discussion among all participants. This summary report would be shared and posted on the CST website. Debrework Zewdie (Washington)
Debrework (Director of the Bank’s Global AIDS Team) gave the background of the Bank’s work on HIV/AIDS since the late 1980s. Initially, the Bank viewed the disease as a health problem, but now treats it as part of the multi-sectoral development agenda. Bank officials include consideration of HIV/AIDS in all discussions of development policies and projects, especially with countries affected severely by AIDS. They take it into consideration when developing Country Assistance and poverty alleviation strategies, and it is usually an agenda item in policy discussions. Now every country eligible for Bank assistance has an HIV/AIDS program, and strengthening relations with CSOs, which implement 50 percent of these programs, is a priority. For example, every country in the Caribbean region will have an HIV/AIDS program by the end of 2004. The Bank is responding systematically to the AIDS pandemic in all regions. A few years ago, only sub-Saharan Africa had an HIV/AIDS strategy; now all the Bank’s regions do. The Bank provides resources – loans and grants – to countries to fight HIV/AIDS. In sub-Saharan Africa, 100 percent of this funding is in the form of grants. Funds are used for prevention, treatment, drug purchasing, etc. In addition, the Bank is doing research on HIV/AIDS’ impact on development and sharing it with member countries. The Bank works with regional and global organizations, including UNAIDS, which the Bank co-founded; the Global Fund for AIDS, TB and Malaria, as its trustee for funds; and President Bush’s HIV/AIDS initiative in 15 African countries. Working with and for civil society, the Bank is giving considerable emphasis to HIV/AIDS. CSOs make a clear difference in the fight against the disease. top Presentation by Armin Fidler (Ankara)
Armin (Health Sector Manager for Europe and Central Asia) began by introducing several colleagues who work with him on the Bank’s regional HIV/AIDS team in Washington. He then stated that the most important element the Bank’s brings to its work in Eastern Europe and Central Asia is using its convening power to get government and civil society to work together to address the AIDS epidemic. He mentioned February’s First European Conference on HIV/AIDS, which covered Western Europe to Central Asia, the richest to the poorest countries. Western Europe has been working on AIDS since the 1980s, and complacency has set in, as AIDS has become a chronic disease. But meanwhile, a nascent epidemic has begun in the former Soviet republics, accompanied by denial about its global impact. HIV/AIDS travels along with intravenous drug users going from Eastern to Western Europe. The problem is now formidable. The rich countries are concerned about the spread (and resurgence) in the European Union, and its epidemiological, social, economic and migration aspects were examined at the Dublin conference. The Bank became involved six or seven years ago, when it started including HIV/AIDS in discussions with the ex-Soviet republics. Resistance to confronting the problem, particularly its link to tuberculosis, was significant. Local medical authorities seemed threatened by new strategies and proposals for combating the disease. In Belarus, the Bank’s HIV/AIDS program was stopped for political reasons. But the Bank did studies and country profiles in Southeastern Europe and the Baltic countries and is working with partners in UNAID, the Global Fund and other agencies. Besides implementing programs and research, we need to listen to people who have links to those personally affected. The WB’s mandate to work with governments may occasionally constrain us from having direct contact with people on the ground, so we can include their perspective in our discussions. Brussels Presentation/Questions
Several AIDS/CSO representatives spoke about the results of the AIDS Action Europe (AAE) Forum, as well as commented and asked questions about the Bank’s preceding presentations. AIDS Action Europe works in partnership with CSOs in 52 Western and East European countries. HIV/AIDS and TB rates are rising in Europe, so Eastern and Western groups need to connect. At the AAE meeting in Brussels, there were 110 participants, including 35 CSO representatives from Eastern Europe. A Powerpoint presentation on the conference will soon be published on its website. In a 2002 report, the CIA noted that 6-7 percent of Russia’s population could be HIV positive. World Bank studies have been useful in pointing out the disease’s economic impact on the region. One participant said he could not find HIV/AIDS-related projects on the Bank’s website. He also asked how much the Bank is ready to enable local CSOs and people with HIV/AIDS in its projects. Another participant, from the Global Network of People Living with HIV/AIDS, said he has been living with the disease for 15 years. Prevention is failing. In Eastern Europe, there is a criminal lack of access to safe injection equipment. He said, we need to provide ways for people to stay healthy through prevention activities. We can’t pretend we’re preaching to a community of the uninfected - people already are HIV-positive. The Bank needs to examine the language (such as “bridging population” or “core transmitter”) it uses about people with HIV/AIDS in some documents. People with HIV/AIDS need to be involved in policy making, not only as beneficiaries of policies.
A participant from Romania summarized the Brussels conference proceedings. In countries where governments are not aware of AIDS, international partnerships make it possible for CSOs to advocate for people with the disease. Representatives from Poland, the Czech Republic, Hungary, Latvia and other countries attended the conference. Now they have more contacts with others to learn how to work with governments. She asked for “help to be more visible in our countries.” top Chisinau Comments/Questions
Several AIDS/CSO representatives in Moldova explained that they have expanded their activities outside the capital city. They are trying to reduce the stigma of having HIV/AIDS among sex workers, homosexuals and drug users. Knowledge transfer is not enough—the Bank should facilitate CSO cooperation among different countries. The Soros Foundation is working with local CSOs. We need to hear from the Bank about cooperation with local and central authorities to reinforce our work on harm reduction. Moscow Comments/Questions
Several AIDS/CSO representatives in Russia explained that they are focusing on ARV (Anti-retroviral) treatment. Problems include a lack of medication, high cost of medication and the medical system’s failure to work with and treat drug users with HIV/AIDS. The Bank could help provide the medical system with expertise, and CSOs could play a crucial role. A participant asked if other CSOs have experience with provision of access to medication. Washington Responses / Comments
Debrework responded to several of the comments and questions. Regarding why all details of Bank-supported HIV/AIDS loan projects aren’t posted on the website, Debrework explained that the Bank works with governments, and that, until the project documents are signed, the government has control over what is disclosed. After the project is effective, information is posted and accessible to the public. The Bank encourages people living with HIV/AIDS and CSOs to participate in dialogue on policies. We can only make suggestions to governments on behalf of CSOs, and some governments accept, while others don’t. Debrework apologized for language characterizing people with AIDS that may seem derogatory but is not intended to be. The Bank is not the only organization to use such terminology. She asked CSOs to continue reminding us when we slip into ‘jargon’ and said the Bank would try to do better.
The Bank hasn’t invested enough resources in HIV/AIDS. But in the past two years, the level of investment has increased greatly. We are committed to continue honoring our pledge to make more resources available. The Bank has not turned down any country asking for resources to fight AIDS. top Ankara Comments / Responses from Washington
Armin welcomed feedback from colleagues in Brussels. Information on loans approved for HIV/AIDS projects is available to the public. If the Web links aren’t clear, we want to know so we can improve them. Many people still believe the Bank implements the projects it supports through loans or credits. This is not the case. The government is responsible for implementing projects; we supervise procurement and negotiate the loan agreement. He welcomed the challenge to do better at influencing governments. We have spoken to the Russian government about the cost of medications, for example. This is one of our priorities as a result of CSO feedback. Russian CSOs visited Brazil and were astonished at how the government and CSOs there were able to lower the cost of ARVs through the use of generics. Olusoji Adeyi (World Bank Lead Health Specialist in Europe and Central Asia Region) in Washington explained how to get access to Bank project information on the website. On the left-hand side menu of the Bank’s main page, click on Projects and Programs and do a search of a country name or a keyword, i.e. Kenya or AIDS. From the list of operations that is generated, click on the one you are looking for and on the page that opens, select to view the Project Appraisal Document (PAD) to read the details. The PAD will contain the name of the Task Manager, whom you can contact for further information. If CSOs can’t find project information, they are requested to contact the Bank. The most useful thing we do, especially in this region, is being a partner in discussions of policy, strategy and program development in many forums. In Russia, for example, the most useful thing we did was to help reach a consensus regarding TB treatment protocols and other issues related to procurement of drugs. We’ve not yet been effective in carrying out prevention on a large scale. Where the epidemics are more mature, it’s easy to say prevention didn’t work, because it wasn’t tried. We need to do more where the epidemic is just beginning. The Bank can get people together who aren’t communicating on their own, such as CSOs and governments. We can work with governments but can’t tell them what to do. But CSOs can participate in implementation of projects. On the issue of language, there is a risk that if too many restrictions are made on the language which cannot be used, there is a danger that it could snowball into censorship. Governments can muzzle the terms of debate, but the danger is that we could end up preaching only to the converted. Joana Godinho (Bank’s Senior Health Specialist and Team Leader for the Moldova Project) noted that Moldova’s AIDS program and the harm reduction component being carried out by CSOs is considered best practice. CSOs from other countries have visited there to see how it works. A conference will soon take place in Moldova, and representatives from other countries should come to share their experiences. Exchanges with CSOs around the world, like this one, are useful; setting them up is a way the Bank can help. Moldova is an example of good partnership among local CSOs, international CSOs, the government and other governments. Local authorities are still not involved, however, in HIV/AIDS and tuberculosis prevention and treatment activities. This will be tackled as the national program advances. The operation in Moldova is the first example of a grant-financed project supported by the World Bank in Europe and Central Asia Region. Other, similar approaches for Central Asia and the Balkans are under consideration. The Global Fund for HIV/AIDS is involved in this undertaking. Moldova Presentation
Two AIDS/CSO representatives from Moldova made a presentation on a harm reduction program in local prisons. The project started in 1999. Its aims are to decrease needle-sharing and distribute clean needles to the inmates. The project has expanded to a women’s prison where 12 percent of these incarcerated people are estimated to be HIV positive. The project provides information on drug-use risks, treatment, social and epidemiological aspects of HIV/AIDS. Its goals are to provide prisons with disinfectants, condoms and information on HIV/AIDS, STDs, hepatitis and tuberculosis. In 1998, there were 38 HIV-positive people in prisons in Moldova; in 2000, 122; in 2003, already 210 that are known to CSOs. This number is not accurate. We can’t afford to test all prisoners, however; we know only about cases after they have been diagnosed. The project aims to reach 11,000 prisoners and 3,000 employees of the penitentiaries in Moldova. We organize needle exchanges and volunteers; changing risky behavior by providing information on diseases and drug use; counseling of HIV-positive people. These activities have had good results. We are also organizing seminars for employees and prisoners. Our biggest problem is getting permission to carry out the project. The Justice Ministry approved it in 1999, but we had to convince prison directors. Three prisons have needle exchange programs, but the others do not. top Moscow Presentation
Several AIDS/CSOs talked about their programs involving youth and harm reduction efforts in Russia. Youth are most vulnerable to HIV/AIDS. There is no system to reach them, no sex education in schools, so they need special assistance. Health Ministry support is needed for CSO activities such as providing information via video materials, posters and events. A representative of the Network on Harm Reduction in Central and Eastern Europe said it was too bad there was no time to comment on the Moldovan presentation. In Russian prisons there are estimated to be 30,000 people with HIV/AIDS. At a meeting with government authorities, CSOs were told there could be no needle exchange in Russian prisons. A number of pilot projects in the area of HIV/AIDS have been completed, and projects are now in operation with Bank and Global Fund assistance. These programs are now controlled by the state, and we have to find a common language with our state so they’ll listen to our experience. We are concerned about the lack of a mechanism to ensure the authorities will listen to CSOs. A representative of Harm Reduction Programs said the most marginalized youth are street kids. UNICEF has supported HIV and hepatitis testing, but the situation is not improving. HIV/AIDS incidence among these street kids is up from 1 to 11 percent. Only the most motivated kids come for help, and in Europe there are only scattered programs for street kids. We tried to work with Street Kids International, a Canadian organization. We need to work with young sex workers, too. In St. Petersburg, 80,000 girls are on the street as sex workers, and most are drug users. An estimated 48 percent of sex workers in St. Petersburg are HIV-positive. A representative from the Drug Policy Alliance said the situation was difficult but promising for drug prevention programs. The government’s attitude is changing, but we can’t predict the direction of the programs. The Russian government’s policies and pronouncements on needle-exchange and other issues affect other government’s attitudes. General Discussion / Comments
A participant from Brussels thanked the Bank participants for being honest and open. She asked if the Bank could support the CSOs when countries make “a mess” in their work with CSOs. Another participant thanked Debrework for her gracious response to his comments about language. We need to lobby governments to guarantee universal treatment across Europe. And we need to apply the experience of activists from mature-epidemic countries to take effective preventive measures elsewhere. It was suggested that the Bank examine Russian drug policies and involve civil society in changing them so they include treatment, harm reduction and prevention. The Bank has an important role in influencing policy change through technical assistance as well as during loan negotiations. CSOs can monitor how governments spend funds, to help the Bank evaluate its projects. Armin said the CSOs’ concerns are in line with the priorities the Bank has identified. Questions include: What comparative advantages does Bank intervention have? What gaps can we fill? High-level advocacy is something the Bank can do; if we call, people show up. Concerns include the high cost of ARVs, especially in Russia, and harm reduction policies in poorer countries. Using a big stick is not the best method. We are keen to keep working with our civil society partners. Soji said the CSOs’ comments were consistent with Bank concerns. The Russian experience included a difficult negotiating process. It is tempting to bypass government and go to the CSOs, but the large scale of government activity makes its participation imperative; there is no substitute for government cooperation. We need to try to build a bigger tent, instead of having an adversarial relationship with governments. A Bank staff member from the External Relations team said inclusion of youth is vital. AIDS Action Europe is a powerful partner and can help share experiences like Moldova’s. The Bank’s Moldova projects manager observed that implementation is easier in small countries like Moldova than in bigger ones like Russia. However, the Brazil initiative was successful because of government involvement at the highest level: the president chaired the AIDS commission. The Bank can be a broker of consensus among sectors and key ministries. Also, the Bank would like to continue its substantive engagement with CSOs working on AIDS, and, as part of that, we want to include youth representatives in the dialogue. Debrework responded to a question by pointing out that mechanisms are already in place for CSOs to send their evaluations to the Bank, which can take them up with governments. One example is the call for universal access as laid out in WHO’s 3x5 initiative. We value dialogue with CSOs, and a face-to-face encounter is planned for mid-May. She concluded by thanking the CSOs for engaging with the Bank. “Don’t give up on us; we make mistakes but try to correct them” she said. John Garrison (Washington)
John concluded by thanking everyone for having participated in the session and stating that meeting notes would be prepared, shared with the participants, and posted on the web site. (1) Attribution is only given to WB staff since it was not possible for civil society participants to review the draft text of their questions and comments. Notes by Linda Rabben Back to Dialogue page |
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