Education + Advocacy = Change

 

Click a topic below for an index of articles:

New-Material

Home

Alternative-Treatments

Financial or Socio-Economic Issues

Forum

Health Insurance

Hepatitis

HIV/AIDS

Institutional Issues

International Reports

Legal Concerns

Math Models or Methods to Predict Trends

Medical Issues

Our Sponsors

Occupational Concerns

Our Board

Religion and infectious diseases

State Governments

Stigma or Discrimination Issues

 

If you would like to submit an article to this website, email us at info@heart-intl.net for a review of this paper

any words all words
Results per page:

“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

 
 

  

 
   
 

 

 

UNGASS: MONITORING CIVIL SOCIETY PERSPECTIVES

LATVIA

A Report Produced for

Panos Global AIDS Programme

by

Roger Drew

Health and Development Consultant

September 200

Glossary

 

AGIHAS            PLWHA NGO in Latvia – Atbalsta Grupa Inficētajiem ar HIV un AIDS Slimniekiem

AIDS                 Acquired Immunodeficiency Syndrome

ARV                 Antiretroviral

CoM                 Cabinet of Ministers

DHS                 Demographic Health Survey

EU                    European Union

HIV                   Human Immunodeficiency Virus

IDU                   Injecting Drug User

ILGA                 International Lesbian and Gay Association

MDR TB            Multi-drug Resistant TB

M&E                 Monitoring and Evaluation

MSM                Men who have Sex with Men

NEP                 Needle Exchange Programme

NGO                 Non-Governmental Organization

PHARE European Union funding programme for accession countries

PLWHA            People Living with HIV/AIDS

PMTCT Prevention of Mother to Child Transmission

TB                    Tuberculosis

UN                    United Nations

UNAIDS            Joint UN Programme on HIV/AIDS

UNDP               United Nations Development Programme

UNGASS          United Nations General Assembly Special Session

UNICEF            United Nations Children’s Fund

USAID  United States Agency for International Development

VCT                  Voluntary Counseling and Testing

VOVAA Valsts obligātās veselības apdro?inā?anas aģentūra (Agency responsible for ARV procurement)

WHO                World Health Organization

 

Project Background and Method

 

This project has been carried out under the auspices of Panos’s Global AIDS Programme as part of a multi-country, collaborative project providing a civil society perspective on monitoring the implementation of the UNGASS Declaration of Commitment[1] (UN, 2001). The work was conducted by a team of two consultants, Roger Drew and Melita Sauka, supported by an Advisory Panel assembled for this purpose.

A preliminary planning trip was made during 7th-10th September with data being collected on a second trip from 20th-29th September. A third trip is planned for November 2005, during which the findings of this report will be shared with members of the Advisory Panel and other stakeholders.

The method followed and the layout of this report are based on a document produced by Panos for this purpose (Panos, 2005b). Key elements included individual and group discussions with key informants[2] (see annex 1) and a review of available literature[3] (see annex 2). A few modifications were made to the generic methodology based on feedback from the advisory panel and other stakeholders. There were some concerns that the generic method developed by Panos was more suited to a generalized epidemic and that some of the language in the questionnaires was quite ‘heavy’. Consequently, these questionnaires were not used as such, rather the methodology document was used as an interview guide.  Some concern was also initially expressed that this process might have overlapped considerably with the official UNGASS process (see UNAIDS, 2005 and annex 4). However, this seemed to happen less than was feared.  Based on a request from the AIDS Prevention Centre, plans to give feedback to the National Steering Committee on HIV/AIDS in November are currently being developed alongside the plans to give feedback to the Advisory Panel. Although the generic methodology largely focuses on government role and responsibility to engage with civil society, this report does briefly discuss issues of civil society capacity and cooperation which are considered relevant in that regard.

Inevitably, there are some limitations to a process of this nature. Time was limited so it was not possible to meet with everyone planned nor to talk with everyone in depth on all topics. As the lead consultant does not speak Latvian or Russian, all interviews were conducted through interpreters, which was particularly challenging when working with Russian-speaking groups, e.g. IDUs.

1.  Executive Summary

Latvia’s national policy on HIV/AIDS is largely encapsulated in a document produced by the Cabinet of Ministers in 2003 entitled Programme for HIV/AIDS Prevention 2003-2007 (CoM, 2003). The objective of this programme is to limit the number of newly diagnosed HIV cases and AIDS spread in Latvia and to lessen their impact on individuals, social groups and public at large. This programme has two priority groups, IDUs and young people and five areas of interventions, namely:

HIV/AIDS epidemiological monitoring;

Prevention;

Health care for PLWHAs;

Training of HIV/AIDS professionals and;

Research 

Key successes of the programme include free provision of ARVs to PLWHAs, improved access to HIV testing and delivery of focused prevention programmes for IDUs, e.g. needle exchange programmes. As a result, based on official data of newly-registered people with HIV infection (AIDS Prevention Centre, 2005a), it appears that the rate of new infections in Latvia has slowed since 2002. However, there could be other explanations for these findings and these findings need to be confirmed from other data, e.g. from bio-behavioral surveys among vulnerable populations.

 

The biggest constraint in the provision of HIV prevention, care and support services is the limited financial resources available. Services financed by central government include ARVs, HIV testing and some focused prevention services. Other services, particularly those provided by NGOs, are funded on a project by project basis with money from various sources, including international donors and local municipalities. Significantly, availability of international funds has been declining because of Latvia’s improved economic position and membership of the European Union. Although some HIV services in Latvia have been provided by funds from the EU, some NGOs, in particular, have reported finding the processes involved in applying for these funds difficult, slow and bureaucratic, and some of the requirements impossible, e.g. the need for pre- and/or co-financing.

 

Although the document describing the National AIDS Programme 2003-7 provides a sound basis overall for the national response to HIV/AIDS, there are some significant gaps. For example, there are no focused activities for some of t FORMTEXT       FORMTEXT       FORMTEXT      he most vulnerable populations, e.g. sex workers and MSM, there is no financial plan integral to the document and the monitoring and evaluation information is weak and incomplete.

 

There are some efforts by government to involve NGOs and PLWHAs in the response to HIV/AIDS. For example, two NGO representatives are members of the National AIDS Steering Committee. However, NGOs and PLWHAs report that this involvement is extremely limited, unsystematic and tokenistic. NGOs in Latvia find it extremely difficult to get funds for HIV/AIDS-related activities and have to compete strongly for these. As a result, the sector has very limited capacity and is extremely fragmented. Staff turnover is high and institutional memory very short.

 

Although many respondents had heard of the UNGASS declaration of commitment and it is specifically referred to in the document describing the National AIDS Programme, there is little sense among stakeholders that it made any difference at all to the response or that it is driving the national response to HIV/AIDS at all. On the contrary, a great deal of scepticism was expressed by respondents about the value of such declarations of commitment at all.

 

The declining availability of international financial resources for HIV/AIDS is affecting the response to the epidemic in Latvia, particularly in the NGO sector. To date, there perceived financial benefit from EU membership in this regard is quite mixed.

 

The final section of this report contains a description of a participatory process for developing concrete conclusions and recommendations including a number of key questions to consider.

 

2. Background

 

2.1 Baseline Statistics[4]

 

General

 

Latvia has a population of around 2.3 million people (UN, 2005), of whom approximately ⅔ live in cities[5]. Latvia is defined by the World Bank as an upper middle income country (World Bank, 2005a) with a gross national income[6] per capita of $5 460 in 2004 (World Bank, 2005b). The annual rate of inflation was reported to be 6.1% as of August 2005 (Bank of Latvia, 2005). Latvia joined the European Union in May 2004.

 

Latvia’s life expectancy at birth is 66 years for males and 76 years for females (WHO, 2005a). Infant mortality rate is 10.2 per 1000 (UN, 2005) and maternal mortality is 61 per 100 000 (WHO, 2005a). In 2002, the per capita total expenditure on health was US$253[7]. Of this, 64% was government expenditure and the remainder was private expenditure. Expenditure on health constituted 9.3% of total government expenditure (WHO, 2005a).

 

Health

 

Latvia’s health system contains a mixture of old Soviet and reformed elements. Primary care in cities is provided through health centres, some of which were originally polyclinics. General practitioners have been increasing their role since 1999. They rent facilities at health centres, operate independently and are financed through the Compulsory Health Insurance Agency. Secondary and tertiary care is available in state and municipal hospitals (WHO, 2004).

 

HIV/AIDS

 

Monitoring of HIV/AIDS in Latvia is the responsibility of the AIDS Prevention Centre who submit regular reports to EuroHIV (EuroHIV, 2004 and 2005). From 1987 to 31st July 2005, a cumulative total of 3 217 HIV infections were diagnosed in Latvia (AIDS Prevention Centre, 2005a). There was a sharp rise in the number of people reported to have HIV infection from 1998 to 2002 but from that time the number has declined (AIDS Prevention Centre, 2005a; Selakova et al, 2003). Although it is likely that this is due to a decline in the number of new infections, some stakeholders believe that other factors may be partially or largely responsible, such as reluctance to seek HIV testing and recent lack of publicity campaigns about HIV/AIDS[8]. According to official figures, there are just over 3 000 people living with HIV in Latvia[9]. However, the actual number may be higher than this. For, example, international agencies estimated that there were 5 000 people living with HIV in Latvia at the end of 2001 (UNAIDS/ UNICEF/WHO, 2002).

 

The majority of those infected with HIV (69%) have had a history of injecting drug use. According to official figures, the number of people infected to date in 2005 through injecting drug use (61) still continues to exceed those infected heterosexually (46)[10]. Although there is a widespread view that HIV is spreading heterosexually into the general population (Eglitis and Cihanovica, 2005), there seems little concrete evidence to substantiate this view. Official figures show that the number of people reporting that they acquired HIV heterosexually remained essentially static since 2001. In addition, official data does not distinguish between those infected through buying or selling sex, sex partners of IDUs or members of the general population. It seems likely that most of the heterosexual spread is in fact occurring in the first two groups, that is it is affecting ‘bridging groups’ rather than the general population.

 

Most of the reported infections with HIV have been in the Riga area, although there are a considerable number from locations on the west coast.

 

Of particular concern is the anecdotal evidence that one third of all new HIV infections are being reported from prisons. This may be due to the large scale testing of people entering the prison system and the fact that vulnerable populations, such as IDUs may be particularly liable to imprisonment. This situation is a cause for concern because of the well-known tendency of HIV to spread rapidly in prisons (Canadian HIV/AIDS Legal Network, 2004), the presence of documented epidemics in prisons in neighbouring countries (CDC, 2002), the known high rates of drug use in Latvian prisons (Institute of Philosophy and Sociology, 2003) and reports that prison authorities in Latvia are more reluctant than previously to implement the measures needed to control the spread of the epidemic, e.g. provision of sterile needles and syringes.

 

Table 1 shows collected data of studies of HIV prevalence among vulnerable sub-populations. This data gives cause for considerable concern. Documented HIV prevalence among sex workers and IDUs is extremely high. For example, more than one in five (>20%) IDUs in needle exchange programmes is HIV positive. Informal verbal reports indicate that recent figures for HIV prevalence among sex workers have risen considerably. Some studies have also shown high prevalence among MSM and prisoners.

 

Table 1: HIV prevalence among vulnerable sub-populations

 

Date

Sub-Population

HIV prevalence

Data Source

Comments

1997

IDUs

6/198 (3%)

Selakova et al, 2003

Same study appears to be quoted in AIDS Prevention Centre, 2005d[11]. Seems to be from new clients in Methadone programme

1997

MSM

5/206 (2%)

Hamers and Downs, 2003

Men in gay clubs

1998

MSM

13/242 (5%)

Hamers and Downs, 2003

2001

Prisoners

4.75%

UNAIDS/UNICEF/WHO, 2002

Results of mandatory testing of new prisoners

2001

IDUs

15.65%

UNAIDS/UNICEF/WHO, 2002

Clinical testing of IDUs

2001

IDUs

36/261 (13.7%)

UNAIDS/UNICEF/WHO, 2002; AIDS Prevention Centre, 2005d

Clients of syringe exchange programme in Riga

2001

Sex workers

7.7% (n=78)

UNAIDS/UNICEF/WHO, 2002

Salivary tests of street sex workers

2002

IDUs

52/250 (21%)

Selakova et al, 2003; AIDS Prevention Centre, 2005d

Clients of syringe exchange programme in Riga

2002

Sex workers

15/92 (16%)

Selakova et al, 2003

Many HIV positive sex workers have history of injecting drugs

NK

IDUs

12%

WHO, 2004

Details of data source not provided

2002

MSM

0/200

Informal verbal report

 

2003

IDUs

45/205 (22%)

AIDS Prevention Centre, 2005d

 

2005

IDUs

71/325 (22%)

AIDS Prevention Centre, 2005d

 

 

From the data available, it appears that Latvia has a significant, concentrated HIV epidemic particularly among IDUs, which is also significantly affecting MSM, sex workers and prisoners.

 

Limitations of these studies include the following:

 

Although the AIDS Prevention Centre reports that these studies are conducted annually, they do not appear to be as systematic and well-documented as might be desirable

 

IDU samples are intervention-based and therefore unlikely to be representative of IDUs as a whole. For example, CDC in Central Asia has shown that IDUs in needle exchange programmes tend to have higher HIV prevalence than those not yet involved in programmes[12] (Drew and Choudhri, 2004)

 

These studies do not seem to be given the appropriate weight when describing the epidemiological situation, when compared to data from case reporting, for example[13]

 

Some key vulnerable populations, e.g. MSM do not appear to be included in these studies, at least not on a regular basis.

 

Staff responsible for these studies have other duties. This is given as the major cause of delays in data availability and analysis

 

Results and analysis are generated slowly and are poorly-disseminated. For example, results of studies conducted at the end of 2004 are still being analyzed and finalized, almost one year after the work was done. There also appears to be some reluctance to publish data which may show a worsening situation, e.g. rising HIV prevalence among sex workers

 

Behavioural analysis seems to be weak or absent from these studies

 

The size of these vulnerable sub-populations is not well-defined.  Stakeholders report widely varying figures for the number of IDUs in the country, from officially registered figures of 5 000 to radio estimates of 50 000. One study reported that in Riga in 2003 there were an estimated 2 295 IDUs (Hay, 2003). Reasonable estimates might be that there are from 4-15 000 sex workers and 24-28 000 IDUs[14] (UNAIDS/ UNICEF/ WHO, 2002; Brussa and Mongard, 2005).

 

A recent large-scale, population-based study of drug use in Latvia (Institute of Philosophy and Sociology, 2003) concluded that:

 

12% of Latvians have tried an illegal drug at least once. This percentage is higher in males (20%) and among young people aged 15-34 (22%)

 

5% of people used illegal drugs in the last year and 2% in the last month

 

The commonest drug used is cannabis. However, there is rising amphetamine and ecstasy use

 

Factors associated positively with drug use are young age, male sex, urban environment, drug use among friends and going out regularly

 

In a related study among prisoners, it was discovered that:

 

31% of prisoners used drugs. This figure was higher than the percentage of those who used illegal drugs in the month prior to imprisonment

24% of prisoners had injected drugs before imprisonment, 14% of prisoners injected in prison

More than 80% of prisoners that inject share needles

 

Unfortunately, information about the risk behaviours of vulnerable populations does not seem to be readily or widely available. There are reports that such studies have been conducted alongside biological surveillance, with the same questions being asked consistently. However, if this data is available, it does not appear to have yet been included in official reports on the epidemiology of the epidemic in Latvia. There have been some one-off research studies on this issue (e.g. Sauka et al., 2003 among MSM).

 

Despite strong evidence of a serious HIV/AIDS epidemic concentrated among some of the most vulnerable sub-populations, namely IDUs, sex workers, MSM and prisoners, there does not appear to be a shared understanding among stakeholders of vulnerability to HIV infection in Latvia and this is affecting the nature of the national response to the epidemic. For example, when asked about who is most vulnerable to HIV in Latvia stakeholders generate a very wide range of responses, including many groups that are considerably less vulnerable than the populations outlined above, e.g. young people and women in general. One possible explanation for seeking to define vulnerability more broadly is that it is easier to work with these groups than those who are most vulnerable. For example, one stakeholder reports ‘ the drug prevention centre should be working in disco bars where young people are taking drugs but they chose to work in schools because it is easier.

 

This is an important issue. Latvia’s response to HIV/AIDS is always likely to have limited resources given that it is not going to be the highest public/political priority. As a result, it is essential that those prevention resources that are available are focused where they are most needed, that is among the most vulnerable sub-populations and not spread diffusely among groups that are likely to have very little exposure to the virus.

 

Tuberculosis

.

Although concern was expressed in 2002 that incidence of TB and MDR TB was high in Latvia and other Baltic States (USAID, 2005), it appears that this peaked between 1998 and 2001 at around 70 cases per 100 000 population and has been declining since (State Agency of TB and Lung Diseases, 2004).

2.2 Political commitment

 

Is HIV/AIDS a priority in Latvia?

 

Although many feel that HIV/AIDS is not being treated as a public/political priority in Latvia, the government’s official position since 1993 has been that controlling the spread of HIV/AIDS is one of the country’s health care priorities (CoM, 1993). This commitment is most clearly expressed in the country’s programme[15] for HIV/AIDS prevention (CoM, 2003) which was adopted in 2003 and covers the period to 2007. Given Latvia’s economic position, the presence of other significant economic, political and health concerns, and the state of the HIV/AIDS epidemic in Latvia, it could be argued that the response is currently correctly prioritized but that what is needed is a sharper focus on preventing spread among the most vulnerable populations and ensuring that all PLWHAs receive the care, support and treatment that they require. One journalist said ‘politicians don’t talk about HIV/AIDS much. There are more important issues like living standards, the salaries of teachers and health staff, corruption and cost of living. Prices went up after joining EU and price of petrol has recently risen.’ In Daugavpils, one journalist said, ‘local politicians never discuss AIDS’. One respondent said that ‘NGOs are more interested in AIDS than the government’.

 

Although this document states specifically that this programme is designed with the aim of implementing the UNGASS declaration of commitment[16], stakeholders seem largely unaware of this and report that they feel little changed in practice following the country’s endorsement of this declaration.

 

Responsibility for implementing the programme rests with the National Committee on the Sexually Transmitted Disease and AIDS Epidemic Control. Although the AIDS Prevention Centre report that this committee consists of 15 members, including two from NGOs[17], the composition and functioning of this committee seems a little unclear to some stakeholders who distinguish between this and an operational ‘steering committee’. According to these stakeholders, the national committee itself is made up of government representatives only. However, other stakeholders, including the AIDS Prevention Centre use the two terms interchangeably. Under this committee, responsibility for epidemiological monitoring and prevention rests with the AIDS Prevention Centre, while responsibility for treatment rests with the Latvian Centre of Infectology. In addition, there are other bodies with related responsibilities, for example the Riga municipality drug prevention centre and the state narcological agency.

 

It is reported that parliament last debated issues relating to HIV/AIDS in 2003 and that this was prior to the adoption of the current strategy/programme. However, parliament was not involved in developing this as it was handled by the Cabinet of Ministers.

 

The National AIDS Programme 2003-7

 

The objective of Latvia’s National AIDS Programme is to limit the number of newly diagnosed HIV cases and AIDS spread in Latvia and to lessen their impact on individuals, social groups and public at large. There are two priority groups described in the document, IDUs[18] and young people. There are five key areas of interventions, namely:

 

HIV/AIDS epidemiological monitoring

Prevention including focused programs for IDUs, prisoners, blood safety, PMTCT, school students and other young people, military recruits

Health care for PLWHAs

Training of HIV/AIDS professionals

Research

 

The programme is reasonably comprehensive in that it includes elements of prevention, care and treatment and impact mitigation. Although it has multisectoral elements[19], the documents reads more like a description of a governmental[20] programme rather than an inclusive, national AIDS strategy/action framework[21].

 

Although there was some involvement of NGOs and PLWHAs in development of the document, most stakeholders considered this to be inadequate and to have consisted of fairly limited/token consultation. Members of the most vulnerable populations, e.g. IDUs, sex workers and MSM do not seem to have been directly consulted. One NGO representative said ‘There was not good coordination and collaboration. I saw a draft of the document and was asked for my comments. However, the process did not seem to be strongly focused on PLWHAs’ One staff member from an NGO was surprised to see their organization mentioned in the document. A person living with HIV/AIDS reported, ‘officially PLWHAs were involved, but they were not so important. It[22] was mostly compiled by specialists’. It appears that the process of compiling the National AIDS Programme document was managed by the Ministry of Health through an international consultant provided by UNDP.

 

However, it should be noted that failure to involve PLWHAs is not a problem limited to government only. It extends also to the NGO sector. For example, one NGO reported that they are planning a study on the sexual and reproductive health of PLWHAs. However, they have no plans to interview PLWHAs for this study, only the doctors that work with them. Reasons given include difficulties in identifying PLWHAs and resource limitations. 

 

The document does have a number of key strengths. These include explicit links to international and national laws, policies and strategies (see annex 3); a clear statement of program’s objective; a brief description of the epidemiological situation; a clear description of responsibilities for different parts of the program; and some guidance for monitoring and evaluating the program.

 

However, there are also some limitations to the document including the following:

 

It does not include activities focused on tackling stigma and discrimination experienced by PLWHAs and members of vulnerable populations[23]

 

It does not specifically include activities for some of the identified vulnerable populations, particularly sex workers and MSM

 

Although the document contains a narrative on funding, there does not appear to be a detailed financial plan included[24]

 

The activities under epidemiological monitoring do not clearly specify which vulnerable populations will be included in surveillance, or if this specifically includes behavioural elements and estimation of population size[25]

 

Prevention activities in prisons do not seem to include key activities, such as needle exchange and drug substitution therapy

 

Some activities are difficult to justify given the state of Latvia’s epidemic, e.g. aiming to test 80% of all pregnant women for HIV

 

It is unclear why some training activities are presented as a separate area while others are integrated into other areas[26]

A national population survey for HIV/AIDS only is clearly not justified. It would be preferable to ‘piggy-back’ questions onto a broader health survey, e.g. a DHS

 

The programme is unclear about the geographical focus/spread of activities

 

Although the document contains a rudimentary M&E plan, it has significant weaknesses[27]

 

The programme has no communications plan

 

It is a little difficult to assess whether or not the programme is ‘on track’ because of the weaknesses of the M&E plan outlined above and the absence of any rigorous review of this to date[28]. However, the main aim of the programme was to reduce the number of newly-diagnosed HIV cases and this has been achieved (AIDS Prevention Centre, 2005a). Assuming that these achievements are both valid and attributable to the program[29], it would appear that the programme is substantially on track.

 

The National AIDS Programme has no explicit communications plan. Consequently, several stakeholders reported that they were unaware of its existence. Others were aware of the document but had not read it nor did they know knew what its contents were. There appears to be little sense of a concerted and coordinated national response to HIV/AIDS. Rather, a number of institutions, particularly governmental ones, are responsible for specific elements of the programme and may communicate with others about what they are doing. For example, the AIDS Prevention Centre has a website and produced an annual report for 2004 (AIDS Prevention Centre, 2005 a and b).

 

Latvia’s legal environment

 

The legal framework for the national programme is presented in annex 3 of this document. Generally, stakeholders reported that they believed Latvia’s laws were satisfactory in this regard but that there is a significant gap in implementation, largely as a result of public attitude towards PLWHAs and members of vulnerable populations. For example, PLWHAs report that they do not reveal their HIV status for fear of losing their job, despite the fact that Latvian law prohibits such action. Although there have been some legal cases which have successfully challenged employment decisions on the basis of discrimination (ILGA Europe, 2005), these appear rare because many people are unwilling for it to be known publicly that they are HIV positive or a member of a vulnerable population. The consequences of such discovery can be severe, for example, ‘One person went to their workplace and discovered that their colleagues had taken all their materials and thrown them away because they had heard they were HIV positive. They heard that they had worn rubber gloves to do this.’

 

During discussions, stakeholders raised a number of issues of legal concern:

 

There are some reports of mandatory HIV testing, e.g. in prisons, of pregnant women, of TB patients and of IDUs in the narcological services. Although it is reported that testing of new prisoners is not mandatory, it appears that very few opt not to be tested. This would raise concerns as to how optional the testing really is. Issue of tests for foreign travel, e.g. friend of respondent who needed a negative HIV test for a job in UK.

 

There is a new law on drug use which criminalizes possession of small amounts of drugs and allows the police to test someone’s blood for drugs without specific reason or consent. It is reported that someone who fails such a mandatory drugs test two or three times can face 1½-2 years in prison. It is reported that this law has made it more difficult for programmes to work with IDUs and IDUs more suspicious of efforts to work with them.

 

Programmes and IDUs also report significant problems with the police. For example, one female street worker reported, ‘Yesterday, I was with another street worker and 4 clients and we were stopped by the police not far from here. The clients wanted to get needles and to talk about rehabilitation. When they saw the police, they ran off. The male police officers searched me and my colleague. It happens often and it is useless to say that I should not be searched by a male police officer... The police know that we are street workers but they treat us as criminals

 

Officially prostitution/sex work is legal but many activities associated with it are not (CoM, 2001). Some of the safeguards that were envisaged, e.g. regular health checks are not fully operational.

 

2.3 Public mobilization

 

Even among those most actively involved in HIV/AIDS-related work, knowledge/awareness of both the National AIDS Programme and the UNGASS declaration of commitment seem low. This is particularly the case for the UNGASS declaration of commitment. A great deal of scepticism was expressed about declarations of commitment, in general, and the fact that they are rarely honoured in practice[30]. If this is the case among those working on the issue, it is likely to be even more the case among the general public.

Based on discussions with journalists, it appears that HIV/AIDS is not a priority issue for discussion in the media in Latvia. Coverage is reported to be limited to articles around World AIDS Day and reports of special projects. A report summarizing all media articles on AIDS in 2001, 2004 and 2005 has been prepared for this study by Latvia’s National Library (National Library, 2005)[31]. However, journalists and the population in general are reported to be much more concerned about economic issues, unemployment, education, health care etc.  This can result in complacency and stigmatizing attitudes towards those to whom HIV is more of an immediate issue. One journalist summed this up ‘If we live normal lives we won’t catch HIV. So, we don’t need to think about it.’ There is said to be more coverage of HIV-related social issues, such as drug use, commercial sex and homosexuality. For example, there was lots of coverage of the Gay Pride march held in Riga in July. However, the population of Latvia is morally conservative. One respondent explained, ‘They prefer families to be “normal”’. One regional newspaper reportedly received complaints from parents after they ran a story about drugs in schools.

 

Consequently, one of the most consistent themes raised in interviews was the very strongly conservative culture[32] in Latvia, leading to severe stigma and discrimination being experienced by PLWHAs and members of vulnerable populations. As many PLWHAs come from a vulnerable population, they experience ‘double’ stigma. Much of this appears to be based on fear. Stigma and discrimination are reported to be particularly strong outside Riga. Examples of discrimination include doctors refusing to treat PLWHAs. One openly gay man reported that he was afraid to go to the health services, other than to his own family doctor, who was reported to be very supportive. One respondent commented that in general people consider male homosexuals to be ‘rubbish’. Many respondents report that they conceal their HIV status and sexual orientation. Interestingly, there may be stigma between vulnerable populations. For example, several of the gay men interviewed talked of IDUs using the same stereotypes favoured by the general population.

 

Stigmatizing attitudes and discriminating practices also exist in the health professions. PLWHAs may find it difficult to find a surgeon willing to conduct elective surgery for them. Pregnant HIV positive women may find it difficult to find a supportive doctor to provide maternity care.

 

There seems to be reasonably high awareness of HIV/AIDS among people in Latvia coupled with knowledge that the disease has been spreading rapidly among IDUs, in particular. There are mixed views as to whether infection is declining, although, on balance, the majority seem to believe that it is. There is, however, a widespread view that the epidemic is spreading significantly through heterosexual spread into the general population, particularly among those working in the field. However, there is no evidence that this is the case[33]. It is however worrying that some members of vulnerable populations, e.g. young gay men, seem to believe that risk of HIV infection is low in Latvia.

 

3. National HIV/AIDS Policy

 

3.1 Policy administration and financing

 

    

Administration of AIDS response

 

As mentioned earlier, the National AIDS Programme is overseen by the National Committee on the Sexually Transmitted Diseases and AIDS Epidemic Spread Control which reports within the Ministry of Health. The Chair and Deputy Chair of this committee both come from the Ministry of Health. Although two NGOs are represented on the steering committee for this body, many stakeholders expressed concern that there does not appear to be a systematic or consistent way of getting feedback from NGOs, PLWHAs and members of vulnerable populations concerning the response to HIV/AIDS. The organizations ‘representing’ NGOs on the steering committee appear to have been appointed by government and not selected from within the constituency[34]. It is reported that the document establishing this committee was updated in July 2004[35]. Since that time, the committee has been reported to have been more active. The committee meets every three to four months and has a strong focus on solving problems, for example, over HIV testing in prisons. The National AIDS Committee does not have its own dedicated secretariat, but the AIDS Prevention Centre report that they perform this role in addition to their other responsibilities. There are reported to be no regional/municipal structures specifically for HIV/AIDS coordination.

 

Two Ministry of Health institutions share responsibility for programme implementation. The AIDS Prevention Centre has responsibility for epidemiological monitoring and prevention while the Latvian Centre of Infectology is responsible for care and treatment of PLWHAs. These institutions are primarily responsible to the Ministry of Health. It is unclear to what extent there is regular reporting/monitoring of the programme as a whole, although some institutions report on their activities at least annually (e.g. AIDS Prevention Centre, 2005b). The AIDS Prevention Centre did produce a report on the programme’s activities for 2003/4 (AIDS Prevention Centre, 2005e) but it is unclear how widely this report has been circulated[36].

 

The AIDS Prevention Centre is structured around two departments responsible for epidemiological surveillance and information/education respectively. There are reported to be 12-13 staff, which is considered adequate for their tasks. In addition to the two main departments, there are administrative staff and a new HIV/AIDS consultation centre located in Riga. In addition, the centre has collaborative contracts with 11 municipalities outside Riga. The AIDS Prevention Centre provides municipalities with information materials, needles and syringes and HIV tests, while the municipalities provide premises and pay staff salaries. Through these collaborative arrangements, a range of HIV/AIDS prevention services are provided including harm reduction activities focused on IDUs, schools education and HIV testing. Condoms are only provided to these projects when funds from specific projects are available.

Some stakeholders expressed concern that the AIDS Prevention Centre has become isolated from work at grassroots level. For example, one said ‘Professionals make good documents and speak well at a high level but they forget what happens in reality in programmes’.

 

The Latvian Centre of Infectology does not work on HIV/AIDS only but on a wide range of infectious diseases. Key HIV-related services include provision of the HIV reference laboratory, which is responsible for confirming all positive HIV tests in Latvia, and the provision of treatment for PLWHAs, including ART. Medical care and treatment for PLWHAs is available on both an in- and outpatient basis.  Screening HIV testing is available through a network of 19 laboratories throughout Latvia. All positive screening tests are confirmed by Western Blot at the reference laboratory at the Centre of Infectology. 

 

In addition, there are two other important structures involved in issues relating to illegal drug use. The first is the Riga Municipality Addiction Prevention Centre and the second is the State Narcological Agency. The AIDS Prevention Centre reports that it participates in steering committees for both these bodies. However, it appears that the Riga Municipality Addiction Prevention Centre has strongly conservative values and is focused almost solely on primary prevention of drug use. Stakeholders expressed strong concern about the value of their work, particularly as it seemed to be focused in schools, rather than in more appropriate locations, such as disco bars. It was also reported that the leadership of this centre was strongly opposed to harm reduction measures, e.g. syringe and needle exchange.

 

As a result, there may be competition and conflict between the AIDS Prevention Centre and other agencies, particularly the Municipal Addiction Prevention Centre[37]. For example one stakeholder reported, ‘One NGO started to cooperate with the Addiction Prevention Centre. The AIDS Prevention Centre was very suspicious and wanted to know what they were doing.’ There may also be areas of overlap and competition between the AIDS Prevention Centre and the Latvian Centre of Infectology. For example, one stakeholder reported ‘the AIDS Prevention Centre is afraid to push too hard for other people to be allowed to do HIV-related consultations, e.g. pre- and post-test counseling, in addition to doctors, in case the Centre of Infectology says it is also going to do more prevention/education activities.’

 

Financing

 

According to WHO, Latvia’s government spending on health was US$130[38] per year in 2002 and this constituted 64.1% of total expenditure on health (WHO, 2005a). It had risen 25% compared to spending levels in 1998. However, the biggest problem relating to mounting an adequate response to HIV/AIDS is reported to be absence of adequate financial resources. It may be useful to try to outline where financial resources come from for the national HIV/AIDS response and how they are spent.

 

However, it is not easy or straightforward to get details of either the overall budget for the national AIDS response or how those monies have been used. Although Latvia has a national health account (WHO, 2005c), there appears to be no sub-account for HIV/AIDS nor a stand-alone national HIV/AIDS account. It is unclear how data required for UNGASS reporting will be collected in the absence of these.

 

Finances for the national AIDS response can be considered under a number of headings. First, there are the funds from the state budget. The bulk of these are for ARVs (around 1.4m lats[39] per year) (Balandina, 2005) and hospital treatment of PLWHAs (around 800 000 lats per year). There is also a smaller amount (around 167 000 lats) for prevention activities but more than half of this is used to buy HIV test kits. Although budget funds for treatment have risen recently, the budget for prevention has been static since 1999 (AIDS Prevention Centre, 2005c). Parliament is responsible for approving the state budget. However, it appears that this is usually done for HIV/AIDS without detailed review of amounts proposed. In addition, it appears that parliament does not review whether the amount spent corresponds to budget. In addition, stakeholders report that, in general, the state’s auditing procedures are weak.

 

Secondly, there are other state funds which contribute to the response to HIV/AIDS but are not covered specifically by the HIV/AIDS budget, e.g. salaries and infrastructure costs in the Latvian Centre of Infectology. However, it would be extremely difficult to get an accurate picture of these costs as staff involved do not work exclusively on HIV/AIDS issues. The true extent of costs of this nature could be large if all HIV-related activities are included, such as treatment of STIs, prevention and control of illegal drug use, TB treatment in PLWHAs etc.

 

Thirdly, municipalities provide funds for activities, e.g. salaries for staff of needle exchange/HIV prevention programmes in Riga, Ķerkavā and other municipalities. However, it is unclear how much this amount constitutes nationally per year. According to estimates from the AIDS Prevention Centre this was more than 100 000 lats in 2004. A key challenge appears to be the division of financial responsibility between national and municipal levels. In particular, municipalities do not appear to have a responsibility to provide services but can opt to do so if they feel they are important.

 

Finally, there are funds from international donors including the EU, Positive Action and others. However, it seems difficult to get a complete picture of these funds. For example, government figures that the country received $312 000 in external funds for HIV/AIDS since 1997 (Balandina, 2005) seem unlikely to be complete, and may refer only to project funds provided to/through the AIDS Prevention Centre. There appears to be no system for reporting or tracking financial resources received directly by NGOs. As a result, there is considerable confusion about who is receiving what money from whom, and how it is being spent. This leads to an environment in which rumours and allegations about how money is used can flourish.

 

In particular NGOs and PLWHAs stated they were unaware of what the government was budgeting and spending on HIV/AIDS. Many expressed the view that they were not particularly interested in this, only in what they could get for their own organization. Consequently, as NGOs are currently not able to get money from the state budget, some expressed the view that the amount in the state budget was of no interest to them.

 

Although NGOs may be able to get some money from municipal sources, many are still dependant on international sources. Some appear to still be able to get significant resources from those sources, while others report that opportunities have declined sharply. Views were sharply divided as to whether or not EU funding is making up for loss of other sources. Organizations which had been successful in applying for EU funds generally reported that it was and that applying for it was no more difficult than other sources. Those that had been unsuccessful reported that they faced problems with co-financing and pre-financing and that the application process was complicated, long and bureaucratic. It does appear that those organizations with more administrative capacity are finding their way through to successfully access EU funding while those with less capacity are not.

 

The lack of consistent and reliable funding for some NGOs means that they tend to lurch from one project to another. When project funding finishes, the activities stop. This can have disastrous consequences for those who were using the services, e.g. NGOs. It means that the national AIDS response does not appear to be a coherent and strategic whole but rather a series of short, unconnected projects. In addition, there is reported to be intense competition between NGOs for available financial resources.

 

Although this report is largely focused on government responsibilities, e.g. to involve civil society and PLWHAs, it is perhaps important to document problems with the HIV/AIDS NGO sector in Latvia that make it difficult for government to meet those responsibilities. These include:

 

Inconsistent funding

 

Limited capacity – the capacity that there is is focused on implementing activities of funded projects and pursuing new funding sources

 

Inter-organizational competition and conflict

 

High staff turnover

 

Poor institutional memory – e.g. one NGO sent a staff member to a training course on how to apply for EU funding. However, she then left and the organization complains that it can not access EU funds.

 

There seems to be extremely limited private sector involvement in response to the epidemic, particularly outside the pharmacological sector. GlaxoSmithKline have large offices in one of Riga’s hospitals and have been involved in marketing their antiretroviral drugs[40], in supporting NGOs through their Positive Action program and in other forms of support, e.g. provision of free over-the-counter medicines. Other pharmaceutical companies are involved, e.g. Merck Sharpe and Dome in Ķerkavā. The Latvian Centre of Infectology reports that Bayer have donated equipment for HIV resistance testing based on an agreement of conducting at least 90 tests per year. Three pharmaceutical companies have agreed to pay for 30 tests each. The AIDS Prevention Centre reports that private companies have supported them by offering discounted prices for videos and TV and other campaigns.

 

3.2 Prevention

 

National AIDS Programme

 

The National AIDS Programme document is not completely explicit about the prevention activities that it covers, although these can be deduced from the tables included under section 7, entitled ‘expected action outcomes’ From these the following activities can be identified:

 

For IDUs – counselling centres, harm reduction programs, substitution therapy

 

In prisons – training of peer educators and provision of disinfectant

 

Blood safety – preparation of guidelines

 

PMTCT – preparation of guidelines, testing and counselling of pregnant women

 

Youth – life skills education in schools, training of peer educators

 

Military – information for recruits and training of military medical personnel