HIV Control Project: Strengthening the supportive environment and scaling up prevention, treatment and care to contain HIV epidemic in the Republic of Tajikistan
HIV/AIDS appears to be a comparatively recent issue in Tajikistan; nonetheless, the increase of HIV infection cases in the country is quite alarming. Over the last 5 years, the number of officially registered HIV cases has skyrocketed by eight times, increasing from 506 in 2005 to 4,674 in 2012. The estimated number of PLHIV consists of 12,759 on average (UNAIDS Spectrum 2012). According to the UNAIDS Report on Global AIDS Epidemic 2012, Tajikistan is among of the countries where HIV prevalence has increased by more than 25% over the last 10 years. HIV-revealed cases were reported in 66 out of 68 districts of the country.
74.5% and 25.5% of HIV infections were reported among men and women, respectively (Statistic data of National AIDS Centre, 2012). Moreover, in recent years, the overall structure of reported cases of HIV-positive women tripled from 8.5% in 2005 to 25.4% in 2012. The number of new cases of HIV infection among women in the last two years has also increased threefold - from 83 women in 2008 to 289 women in 2012.
While the government has taken the first steps in addressing this issue through the development of the National Programme on HIV/AIDS (2007) and the establishment of the National Coordination Committee for HIV/AIDS Prevention, an appropriate effort has not been made to provide governmental funding to HIV/AIDS projects. This financial gap has largely been filled by the Global Fund since 2003.
Accordingly, a comprehensive and fully-fledged approach is crucial to continue keeping HIV epidemic in concentrated stage in Tajikistan. Aligned with targets for MDG6 Halt and begin to reverse the spread of HIV/AIDS UNDP in Tajikistan intends to control HIV infection nationwide through increased HIV/AIDS awareness to influence positive behavioural change, increased access to voluntary confidential counselling and treatment and testing, stigma reduction, improvement of human resource development and training for effective HIV/AIDS prevention, care and support, provision of test kits, Anti-Retroviral Treatment, and other medical supplies at health facilities across the country.
The HIV Control project aims to scale-up equal access for all segments of the population, including most at-risk and vulnerable groups to HIV prevention services, while also achieving the following key outcome and impact indicators by September 2015:
- HIV prevalence is not more than 20% among IDUs, SWs, MSM and 1% among pregnant women;
- 90% of adults and children with HIV known to be on treatment 12 months after initiation of ART;
- 75% of IDUs reporting the use of sterile injecting equipment the last time they injected;
- 80% of female sex workers reporting the use of a condom with their most recent client;
- 75% of MSM who have adopted behaviours that reduce transmission of HIV (i.e. using condom consistently);
- 85% of health professionals who demonstrate readiness to provide health services to PLHIV and vulnerable population groups at the same quality level and with the same attitude as to all other people.
In connection with the above-stated indicators, UNDP intends to reach high risk groups such as IDUs and SWs as the main drivers of the HIV epidemic in Tajikistan. Proposed prevention services include: harm reduction programme via community outreach and peer-to-peer education; distribution of prevention health commodities and dissemination of information and communication materials; promotion of support services (e.g. voluntary counselling, HIV testing, referrals to specialized services, management of sexually transmitted diseases, etc.); promotion of supportive, non-discriminatory home and work environments through strengthening advocacy and communication activities to civil society. Furthermore, UNDP desires to enhance capacity of healthcare facilities in providing quality antiretroviral therapy.
- Due to effective implementation of HIV comprehensive prevention programme in the country, HIV epidemic is kept in the concentrated stage as per the Ministry of Health of the Republic of Tajikistan (based on results of 2011 BSS)
- Harm reduction intervention as per the GF Harm Reduction Information Note (2010) is successfully being realized in Tajikistan for most at-risk and vulnerable groups:
- Needle and syringe programs (NSPs)
- Opioid substitution therapy (OST) initiative launched since 2010
- HIV testing and counseling
- Antiretroviral therapy (ART) started 2006
- Prevention and treatment of sexually transmitted infections
- Condom distribution programs for people who inject drugs and their sexual partners
- Targeted information, education and communication
- Vaccination, diagnosis and treatment of viral hepatitis
- Prevention, diagnosis and treatment of tuberculosis
- The HIV prevalence among IDUs dropped from 19.4% in 2007 to 13.5% in 2011;
- In 2010 64,5% medical staff agreed to examine PLHIV on equal terms with other patients and the results of 2012 survey increased by 74,3%;
- All registered pregnant women get HIV testing and counseling since 2011;
- Level 3 Bio-Safety Laboratory has been constructed to detect communicable and most hazardous diseases including HIV, TB and Malaria;
- Coalition/umbrella approach initiative has been piloted to further build the capacity of CBOs for quality coverage of risky groups of population.
Tuberculosis constitutes a serious problem for the country: In Tajikistan annually 6,000 to 8,000 new registered cases of tuberculosis are detected and it is a growing trend. In 2012, the incidence rate reached 80 per 100,000 persons. One of the serious challenges of the National Program is a high rate of multi-drug resistant (MDR)-TB, 16.8% among new cases and 61.6% among previously treated TB patients, as well as a growing trend of HIV-infected patients among TB patients.
UNDP supports the Health Sector Reform that was approved by the Tajik Government. The reform is an important part of Tajikistan’s Medium-term Living Standard Improvement Strategy, and its implementation significantly contributes towards the country’s achievement of the Millennium Development Goals (MDGs).
UNDP has been implementing TB project since August 2007. The main goal of the project is to reduce the burden of TB in the Republic of Tajikistan by 2015 in line with the MDGs and Stop TB Partnership targets that aim at strengthening TB prevention and control in the framework of health system reform.
UNDP’s TB Project activities are focusing on achieving the following objectives:
- Ensuring high quality DOTS expansion and enhancement actions;
- Addressing TB/HIV, MDR and other challenges of the National TB Program;
- Ensuring practical approach to lung disease;
- Engaging all care providers to TB activities;
- Empowering people with TB and communities;
- Promoting TB Operational researches; and
- Strengthening cross cutting issues of health system.
UNDP has provided sound technical support in development of the National TB Control Programme for 2010-2015 that has been endorsed by the Parliament of Tajikistan. Sound technical assistance is also provided in implementing objectives of the National Programme as well as in strengthening the capacity of the Government health structures. Only in 2012 over 400 specialists of PHC and TB centres were trained inside the country as well as outside. Extensive technical assistance was provided to implement and strengthen TB activities as well as TB/HIV, MDR-TB, PAL and other components of the National TB Control Programme. So far, over 50 technical documents have been developed in the areas of TB control, MDR-TB, TB/HIV, infection control, Laboratory, drug management, etc.
Special attention was given to involvement of civil society organization in implementation of activities focused on TB prevention, diagnosis and treatment within communities through contracting local and international public organizations. Considerable improvements are achieved in directly observed treatment of TB and MDR-TB patients using the network of community volunteers, particularly, in remote areas where access to health services is limited.
Today, with support of UNDP, TB patients in all districts and regions of the country are ensured with universal access to TB diagnosis and treatment. Other achievements include high treatment success rates, strengthened TB laboratory network, infrastructure development, successful project/programme implementation, TB/HIV and community DOTS and MDR-TB programmes. With UNDP initiative, capacity assessment of the Ministry of Health and its readiness to take over PR-ship for implementation of GF grants was conducted and draft transition plan is provided.
- All TB patients are provided with universal access to TB treatment, annually 7,000 to 8,000 (100%) registered in the country including the penitentiary sector receive treatment with first line TB drugs
- The country successfully has introduced MDR-TB (DOTS Plus) project and, by now, 1,300 patients are enrolled for MDR treatment with second line TB drugs
- More than 2,000 health providers are trained in various aspects of TB including DOTS, MDR-TB, TB/HIV, PAL and other trainings
- Over 90% of all TB cases are tested on HIV annually
- Over 100 TB centers and laboratories are established and rehabilitated as well as 4 new TB Hospitals including TB Prison Hospital constructed;
- Network of microscopy and bacteriology laboratories is established including supply of equipment, reagents and consumables.
- New Level 3 Bio-Safety Laboratory is constructed in Dushanbe allowing detection of communicable and most hazardous diseases including HIV, TB and Malaria
- Community based projects with involvement of civil society organization introduced for awareness-raising activities as well as treatment adherence as support in providing DOT for TB and MDR-TB outpatients
Malaria Elimination in Tajikistan for the period of 2009-2014
The ultimate goal of the project is to interrupt the transmission of malaria by 2015 following by certification of malaria elimination. In areas where malaria had been eliminated, attention is given to maintaining the malaria-free status through strengthening malaria surveillance system, capacitating national counterparts in early detection and effective treatment as well as promotion of integrated vector control management. Accordingly, UNDP in Tajikistan has put considerable efforts to achieve national targets in line with targets for MDG6 Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases and the National Strategy Programme until 2015; namely, the Malaria Control Project has succeeded to reduce the malaria infection rate by five times from 165 cases in 2010 to 33 incidences in 2012 as well as eradicate the P.falciparum form of malaria in the country as of 2009.
Currently, the Malaria Control Project is mainly focused on the following components:
- Improve capacity within the NMCP to support malaria control policy development, planning, management, partnership and coordination.
- Strengthen the national surveillance system, including epidemic forecasting, early warning and response.
- Improve the coverage and quality of early diagnosis and prompt treatment services in the country
- Promote cost-effective integrated vector management based on indoor residual spraying, larvivorous fish, bed-nets and environmental management
- Provide the evidence required to allow appropriate and effective malaria control strategies responsive to the rapidly changing disease context through a program of needs-based operational research.
- Expand Behavior Change Communication through the media and community mobilization strategy
The impact indicators are the incidence of malaria in the target areas, which reflect the effectiveness of the preventative measures implemented, and enhance public knowledge about control measures with demonstrated behaviour change in the targeted population, reflecting the acceptability of interventions and their effectiveness. In line with the WHO regional malaria elimination strategy it was planned to eliminate P.falciparum malaria by the end of 2010 and in practice, since 2008 Tajikistan has not registered any local P.falciparum, which can be considered as a met target.
Consequently, the UNDP expects to strictly maintain the current situation and keep the following outcome indicators by September 2015:
- 100% of outpatient cases that received appropriate antimalarial treatment according to national guidelines;
- 100% of households in focus region with at least one insecticide-treated net;
- 100% of households in targeted areas that received IRS in the last 12 months.
Overall project performance can be considered successful as all the indicators set for the year 2012 were achieved on a high standard level. Furthermore, it is planned to support 310 existing health and laboratory facilities with necessary items for diagnosis, treatment and implementing quality control procedures. UNDP prioritizes the capacity building activities among health service providers; up to now, approximately 686 (118.3%) healthcare specialists have improved their knowledge and skills in malaria (active and passive) case detection and timely prevention and treatment. One of the important interventions is vector control and, as of date, 83,856 (100%) households have been sprayed by alphacipermetrin insecticide. As well, cumulatively 356,690 bed-nets have been distributed to population living in malaria-prone areas since 2006. The national source (RTDC) reported having 22 (275%) potential foci registered in 2012 compared to 58 registered foci in 2011.
Last, but not least, one of the important project indicators is increase of knowledge on malaria preventive activities among population. The project planned to educate 31,500 schoolchildren in 15 project districts located in malaria prone regions, while in fact, 31,950 schoolchildren have been educated by school teachers.
- Malaria case detection has significantly reduced by 70 times (33 incidences in 2012) since 2006 (2,309 incidences);
- The country is staged on malaria pre-elimination phase now. It is anticipated to carry out the evaluation of Malaria Control Programme in 2013 by an international independent consultant to propose Tajikistan to obtain the WHO certification as a malaria-free country;
- A guideline on Malaria Control for healthcare workers is being revisited with the purpose of updating testing of G6PD for infected patients;
- Due to project support, the National Malaria control program eradicated the P.falciparum form of malaria in the country as of 2009.
Figure 1. Main phases on the way to malaria elimination