Kyrgyzstan: Protecting the privacy and dignity of people living with HIV and AIDS
By Larisa Bashmakova and Jyldyz Kuvatova
Bishkek, Kyrgyzstan – When he learned that he had acquired HIV from injecting drugs, 35-year-old Mirlan (not his real name) sought help from the Regional AIDS Prevention Centre in Jalalabad, Kyrgyzstan. One day in 2005, television reporters showed up with a request to film the Centre’s work.
Hoping to attract attention in the press, the chief physician asked Mirlan to do an interview with the reporters. He refused, but still ended up on TV, clearly identified as a person with HIV. While Mirlan wasn’t looking, the doctor had held open some curtains so the reporters could film him without his knowledge.
- Kyrgyzstan’s location, at the crossroads of drug trafficking through Central Asia, has helped drive the number of injecting drug users up by 50 times in the last two decades, with a current total of around 25,000.
- In 2000, UNDP helped Kyrgyzstan become one of the first countries in Central Asia to pilot syringe exchange programmes.
- In 2011, the Global Fund for AIDS, Tuberculosis and Malaria agreed to provide Kyrgyzstan with US$31 million toward the goal of universal access to services for people living with HIV.
After the broadcast, Mirlan’s life took a dramatic turn for the worse, deepening the downward spiral that began when he stopped taking anti-retroviral drugs and lost a successful business. People jeered at him on the streets of his small provincial hometown, and refused to serve him in stores. Classmates at school called his children “AIDS carriers.” Under great emotional duress, his mother died from a heart attack. Mirlan, despite his rapidly declining health, filed a case in court, helped by a UNDP-supported legal aid clinic.
He would not live to see the end, but he would leave a legacy: a landmark judgment against the doctor. For the first time in Kyrgyzstan, a court case legally upheld the human rights of a person living with HIV. It was possible because the Government, advised by UNDP, had adopted a new AIDS Law to protect people like Mirlan.
Putting the pieces together
A small country with a limited economic base, Kyrgyzstan has faced a challenging transition from the days of Soviet dependence. Budgetary resources have been short, and health care spending has declined sharply, even as a new threat from HIV began to emerge.
Kyrgyzstan still has a relatively low prevalence of HIV but the virus is spreading at one of the fastest rates in the world. The country’s location, at the crossroads of drug trafficking through Central Asia, has helped drive the number of injecting drug users up by 50 times in the last two decades, with a current total of around 25,000. Mostly men, they account for about two-thirds of HIV cases. Recent increases in the number of women and children with HIV indicate the epidemic is slowly but surely spreading into the general population.
Stopping the spread of HIV requires coordinated actions on many levels: new laws and state programmes, prevention and care services, resources, partnerships and behavioural changes. Kyrgyzstan started with few of these pieces in place. But with assistance from international partners such as UNDP, it has begun to put them together.
Protection under the law
Early HIV initiatives focused on directly reaching communities most vulnerable to the virus, especially injecting drug users. In 2000, UNDP helped Kyrgyzstan become one of the first countries in Central Asia to pilot syringe exchange programmes. In 2002, it became the first country in the Commonwealth of Independent States to offer methadone substitution treatment to heroin and opium addicts.
Important momentum came in 2005 from a new national AIDS law that UNDP helped to develop and get approved by the Parliament. That law is now considered one of the best of its kind in the post-Soviet region. It grants priority access to primary care facilities and medication for people living with HIV, and stipulates punishments for cases of stigma and discrimination against people living with HIV and AIDS — like the one Mirlan filed. For the first time, the law called for legal distinctions between voluntary and compulsory HIV testing, with a requirement for informed written consent in all cases except those mandated by court order.
Subsequent policies and regulations built on the new law. The Criminal and Administrative Code partially decriminalized some activities involving drugs without an intention to sell. In 2007, a new regulation encouraged referrals of drug addicts to syringe exchange and methadone therapy programmes, rather than simply carting them off to jail. This measure has helped reduce the overall number of prisoners in Kyrgyzstan by almost half, from 17,000 in 2007 to 9,500 in 2009.
To support these changes, UNDP has helped government officials develop a training programme on HIV for law enforcement agencies. An order from the Ministry of Internal Affairs now requires all police officers working with high-risk populations to learn about issues such as the vital importance of needle exchange programmes in protecting key populations at higher risk, and the rights of people with HIV under the Constitution and other laws, as well as personal protection measures.
The difference can be seen on the streets. Police officers who once harassed and arrested injecting drug users now send them to programmes that can save their lives.
Improving plans and services
The year after the 2005 AIDS Law, the Government adopted a national AIDS programme to conform to it. The programme built on the latest international standards, such as by covering actions in the multiple arenas required to address HIV, including health, justice, law enforcement, education, social protection and information. It prioritized at-risk populations, such as injecting drug users and prisoners. To implement the programme, UNDP, in cooperation with other international organizations, assisted with setting up a national committee to coordinate HIV activities, along with a unified system for monitoring national and provincial activities.
The programme has helped ensure that HIV and harm reduction services — comprising testing and outreach, as well as syringe exchanges and methadone substitution programmes — now reach 60 percent of injecting drug users. By 2011, the Ministry of Health was operating 30 methadone treatment centres. Three additional programmes were running within prisons. In Bishkek, which has had some of the longest-running needle exchange and methadone treatment services, HIV infection rates among users are half the national average.
Consultations on testing have been introduced in healthcare organizations across Kyrgyzstan, and public advocacy has conveyed the message on billboards, radio and television, that testing is an important routine medical procedure. Around 350,000 people now undergo it each year.
The national programme has strongly emphasized civil society participation in stopping the tide of HIV infections. Under the protections of the 2005 AIDS Law, more groups of people living with HIV have formed, and civil society leaders, for the first time in Central Asia, have publicly emerged from marginalized communities, including former injecting drug users, sex workers and men who have sex with men.
UNDP has worked closely with these groups to provide seed funding and develop the technical skills they need to advocate, run organizations and provide services, including in connection with the public health system. As HIV threatens to spread beyond injecting drug users some non-governmental groups have pioneered Kyrgyzstan’s first services tailored to women and girls living with HIV.
Other essential civil society contributions have come from religious leaders. Since Kyrgyzstan is a majority Muslim country, UNDP engaged the Spiritual Administration of Muslims of Kyrgyzstan and the State Commission on Religious Affairs in training Muslim imams to help break through the silence, fear and lack of knowledge that often surround HIV. In worship services and other religious activities, they preach about healthy lifestyles and the need to respect one another, regardless of HIV status.
“Everything I do in order to stop HIV is done in the name of God. I am helping people to avoid misfortune and sorrow,” says Maksutov Jusupjanajy, the Chief Imam-Hatib of the Alai District in Osh Province.
Aiming for universal access
Kyrgyzstan today has a foundation in place for stopping the spread of HIV. But it faces formidable hindrances to its next challenge: rapidly expanding the coverage and quality of HIV care and prevention services so that everyone has access to them.
The obstacles include ongoing political and economic instability, and the cross-border flow of narcotics, which continues unabated. The fact that HIV infections appear increasingly in small rural communities with limited medical care may prove to be an extra burden on an already overstretched healthcare system. And Kyrgyzstan is highly dependent on external financing for HIV programmes that has declined considerably in the face of the global economic crisis.
Hope comes from the growing cadre of officials and civil society advocates who have gained experience in working on HIV programmes sponsored by UNDP and other international partners. The latest national HIV prevention programme, drafted in 2011, aims for a full menu of protection and prevention services in all healthcare locations, and its targets include ensuring that over 80 percent of children and adults with AIDS can receive anti-retroviral treatment, up from 23 percent at present.
In 2011, the Global Fund for AIDS, Tuberculosis and Malaria agreed to provide Kyrgyzstan with US$31 million toward the goal of universal access to services for people living with HIV. Much more will be needed to hit that goal, but it is an important advance in the right direction for a country striving to stop a terrible epidemic.
Additional reporting by Janyl Rakhmanova