©2016 Brendan Hoffman, Global Fund Advocates Network
An interview with Anton Basenko, Harm Reduction Projects Coordinator at the Alliance for Public Health Ukraine, Board Member of the International Network of People who Use Drugs for the Eastern Europe & Central Asia Region, and Member of the Communities Delegation to the Global Fund Board.
“One year before I started Opioid Substitution Therapy (OST), I joined a harm reduction programme and met people from non-governmental organisations (NGOs) who were providing clean syringes. They were very inspiring and very positive to us. Then I started sharing information with my peers, street drug users.
I gave my first public speech in 2005 since I was one of the first persons to be part of an OST programme in Ukraine, which started in 2004. Six months into the programme, I was invited to the first Ministry of Health public hearing, where the decision on whether it would become permanent was to be made. This was the first time I told my story and experience as a drug user within this OST programme, and this is how my activism work started.”
Harm reduction programmes are key mechanisms in the fight against HIV, hepatitis and tuberculosis (TB) and help limit new infections. I call them “an entry point to a new life” since they are the starting point for all further programmes: 99 percent of people using drugs, who are HIV positive and are on antiretroviral therapy (ART) treatment, come from harm reduction programmes. They ensure that you, as a drug user, come in contact with medical staff and social services.
People who use drugs are hard to reach. Before, hotspots on the streets were well known, we knew where to find needles and reach the right persons. Nowadays, a lot happens through hidden contacts, drugs are bought through the internet, and there is an increased number of non-injectable designer drugs and young users, though injecting drugs is still very popular. Although no needles are used, the risk of HIV and hepatitis C infection is still high because of the behaviour alteration induced by these substances. This evolution raises questions amongst medical services providers.
Over the past 15 years, revolutionary changes have happened. The needle and syringe programmes are a striking example: when I started working in this field, thousands of people were receiving clean needles and syringes and hundreds of them were on opioid substitution therapy (OST). Now, Ukraine has the biggest harm reduction and OST programme in the Eastern Europe & Central Asia (EECA) region: approximately 220,000 people are following a harm reduction programme, and almost 11,000 people are on OST, there are 200 substitution therapy sites as well as take-home solutions, which means that you no longer have to visit a clinic every day.
Access to antiretrovirals, TB and hepatitis C medicines could be somewhat different, but we do have them compared to other countries, and this is great. Positive changes have been made and we have seen improvements, for example new medicines are made available in a way which makes them easier to access. As I discuss below, the MPP has played an important role in ensuring that new treatments become available faster and affordably in Ukraine and other EECA countries. This will be important, as the countries face transition from international donor funding to domestic funding.
Yet, if we want people to get a better life and better opportunities, several issues remain to be tackled in the EECA region, such as securing public health funding, human rights for key populations and access to treatment.
The affordability of medicines may become an issue in the light of countries’ transitions to domestic funding. The issue of funding is key to understand the current situation. Success stories in harm reduction have been possible in Ukraine with international donor funding, such as the Global Fund. While its new grant provides for a scheduled transition to domestic funding from 2018, the preparedness of our country for programmes targeting HIV, TB, hepatitis B and C and substitution therapy is a question mark. Our biggest challenge now is to safeguard all the success gained so far. This year is therefore critical to our community, since this transition period is an unstable and risky one. What is worrying us is the possibility that only the procurement of medicines may be funded, while prevention, social and psychological support may no longer be supported. The new 2019-2023 national HIV/AIDS programme in Ukraine will be adopted in 2018. This roadmap encompasses HIV policy as well as funding commitments. We are pushing for human rights as well as gender and community rights to be included, and for provisions to increase access to substitution therapy and hepatitis C treatment.
There is real evidence of the preparedness of the Ukrainian government to hear our voices and involve users in decision-making processes. What happened last year was revolutionary: for the first time in its 12 years of existence, the National Council on TB and HIV/AIDS opened up seats to people who represent key affected populations (including people who use drugs, sex workers, and men who have sex with men).
Meanwhile, stigma and discrimination – which are still very high and widespread across Ukraine and the EECA region – are another challenge. Key populations, such as people who use drugs or sex workers, are criminals according to the law. Being discriminated against marginalises them and drives them underground where they have no access to medical services or treatment. I must add that over the years, we have felt changes in the way medical staff and law enforcers are behaving, and this is a very important step.
In addition to key populations having difficulties accessing treatment, Ukraine is still in a conflict situation and this impacts people’s lives in all possible ways. About 1.7 million people have been internally displaced, including people who need medical services. To continue treatment or access life-saving medicines has become extremely difficult for them.
Ensuring that people affected by hepatitis C or TB get treatment is not easy. Thanks to all these years of progress, information and education about HIV and AIDS – as well as proper funding and engagement – people now know about the disease and know that treatments exist. Hepatitis C and TB, on the contrary, have suffered from a lack of funding and interest, the consequence now being that people know less about them than they do about HIV. Tackling these diseases will only be possible through extensive work from all actors: from the government to NGOs to people who are affected.
It is of the utmost importance that patients get access to quality-assured generic medicines. Especially during times of transition, it is important to make sure that governments are aware of the existing and possible opportunities to procure generic WHO-recommended medicines. In this area, the public health-oriented licence agreements negotiated by the Medicines Patent Pool (MPP) with pharmaceutical companies can help: many countries in the EECA region should now be able to procure less expensive generic versions of WHO-recommended medicines, such as dolutegravir (DTG) and its combination with tenofovir and lamivudine (TLD), TAF for HIV and potentially ravidasvir for hepatitis C treatment if it is approved.
Civil society and communities can help, as they can make their governments aware of these opportunities, advocate for timely procurement, updated testing and treatment guidelines, and for prevention, treatment and care programmes.
Right now, we have a lot of work on our hands. We need to make a push within the communities in Ukraine so that they realise that the next three years will be decisive. We need public action, we need to work on our advocacy plans and move things forward.
Let’s treat hepatitis C, video blog series published on the Alliance for Public Health website: http://aph.org.ua/en/resources/useful-information-for-partner-ngos
 The number is similar for hepatitis C and tuberculosis.
 In Ukraine, the National Council on TB and HIV/AIDS is the Country Coordinating Mechanism (CCM) – under the Cabinet of Ministers – which coordinates HIV, TB and responses to other diseases.
 “War in Ukraine has escalated HIV spread in the country (January 2018)”
 Both now are WHO-recommended first-line treatment for HIV.
 Ravidasvir can be used when daclatasvir is unavailable and combined with other DAAs such as sofosbuvir.