HIV@MSD - Facing the Facts: Estonia gets to grips with HIV

Fighting HIV/AIDS at the grassroots in Estonia

While estimates vary on the number of people living with HIV/AIDS in Estonia today, there are more than 6,000 cases already registered (of a total population of 1.35 million). These are mainly young people and IDUs (Injecting Drug Users) in Tallinn and in the north-east of the country along the Russian border, where people live in extremely precarious conditions.

Where does the epidemic originate?

It is common knowledge that until 2004, IDUs were the main contributors to new HIV infections in Estonia, constituting 90% of registered infections. By, 2006, however, the epidemic had progressed, and IDUs constituted 50% of new infections, according to national statistics. The 15 to 29 age group was and still is the hardest hit group.

If the number of IDUs and commercial sex workers (CSWs) is stable and under control as government statistics suggest, where are the new infections coming from? It is worth noting that over the last two years experts have seen a change in the HIV statistics with a shift in gender (more young females infected than males) and a shift in the mode of transmission, with a growing proportion of non-IDU, non CSW people becoming infected. These developments indicate that the infection is beginning to spread in the general population.

Of course there are other groups at risk to HIV infection and they must also be reached in government programs: these include people living with HIV/AIDS (PLWHAs), partners of IDUs, CSWs including males, men who have sex with men, and prison inmates. For many of these people, however, the only source of social support is the local NGOs.

Estonia In the impoverished north east of Estonia, ethnic Russians "marooned" after the collapse of the Soviet regime huddle together in a 'little Russia', where alcoholism and cheap heroin are easy bedfellows. Early drop out of school, unemployment and homelessness are often at the origin of drug and/or alcohol addiction. Yet they chose to stay put rather than go back to Russia where there was no infrastructure for their re-integration.

It is not hard to imagine the explosion of HIV in this marginalized area. But it is unclear exactly how many people are affected because they are the invisible, the anonymous, and often the criminal element of the population. The local NGOs which have been working for years with these groups have a good idea of the gloomy reality.

Estonia Since Estonia's independence from the Soviet Union in 1991, a second generation of Russians has been born in Estonia. But like their parents, many of these young people do not speak Estonian well and remain socially excluded, often lacking the Estonian citizenship which would entitle them to health insurance and government health services.

Language barriers also prevent many HIV positive people from gaining awareness about how to protect themselves and that they can get free treatment.

Integrating this non-Estonian community into the national health system is one of the toughest challenges facing the government. But because it interlinks human rights, health, social and political issues and implies a lot of changes, government seems to have relegated it to the 'too-hard' basket for the time-being.

According to Dr Jarno Habicht, World Health Organization (WHO), Head of Country Office in Estonia, "Estonia could have universal health coverage in the next ten years, it's just a matter of taking the political decision". Despite these encouraging words, these marginalized people still have little choice but to rely almost entirely on NGOs, which receive much of their funding from the public sector, for support and care. Additional political will should strengthen the outreach and coordination necessary to assure more timely treatment and more comprehensive care.

What's being done?

So what is the Estonian government doing about this emerging crisis? It has set up cross-ministerial HIV/AIDS programs and has benefited from technical and financial support from partners such as the WHO, the World Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria (see Box), as well as from the experience of neighboring countries.

The Global Fund in Estonia
http://www.theglobalfund.org/search/portfolio.aspx?countryID=EST

The Global Fund to Fight AIDS, Tuberculosis and Malaria was created to finance a dramatic turn-around in the fight against these diseases. It operates as a partnership between governments, civil society, the private sector and affected communities. In Estonia, the Global Fund provided a US$10.09 million grant for four years from October 2003. Today, with a year and half to go before the program ends, US$ 5.1 million have been disbursed. Its ambitious goal was to stop the progressive spread of HIV in Estonia by 2007.

The recipient of these funds is the National Institute for Health Development of the Ministry of Social Affairs

Many beneficiaries of Estonia's Global Fund grant worry what will happen when the grant runs out. Will the government have built the necessary 'bridges' to continue projects initiated with the Global Fund money and to work with its partners from the private and NGO sector? So many questions remain unanswered, but they must be clarified soon if a sense of 'teamwork' is to be maintained among the stakeholders.

Many HIV experts fear that the consequences of HIV/AIDS on society and the economy are still greatly underestimated by the government and the public. According to a policy think-tank in Tallinn, the AIDS epidemic will undoubtedly appear in the coming years, after a 10 year window following the HIV epidemic. It will include a lot of currently unidentified HIV cases and once again Estonia will be surprised by the fast increasing number of AIDS cases and its macro-economic impact on the whole society. It is said that the government should communicate now on its ability to provide the full range of services (including the supply of antiretroviral therapies) for the day PLWHAs will come forward.

Because the Estonian government is focused on a range of reforms that affect primarily the main population, marginalized vulnerable populations remain underserved and cannot get the services they need. As Estonia struggles with reforms, it looks to its Nordic neighbors for guidance on social policy, but lacks the resources to replicate a Swedish or Finnish model. Coming out of many years of Soviet domination, Estonia is really struggling with how to get the public private mix right and how to forge effective coalition in service planning and delivery between the government and civil society.

One of the government's most urgent tasks is to find out exactly how many people are infected with HIV. Otherwise:

How will it allocate enough money for HIV care and treatment, and for purchasing antiretroviral (ARV) treatments for ALL those who will need them in the coming years?
How will it ensure there will be enough treatment centers able to deliver ARVs and ensure the necessary pre and post diagnosis counseling?
How will it train and retain sufficient medical staff and health workers to provide quality care and support to PLWHAs?
How will it implement enough sustainable programs to improve the life of PLWHAs (housing, jobs, needle exchange schemes etc.)?
How will it adequately track the follow-up of patients in need of treatment?
How will it support methadone distribution centers and enable IDUs to live a more stable life away from heroin, while waiting for their ARV treatments?

Estonia's entrance into the European Union further complicates the problem. Before 2004, Estonia could appeal for funds from international organizations like the Global Fund. Unfortunately, EU membership excludes Estonia from such opportunities. One of the only solutions left is to apply for funds through the EU Public Health program; the Commission publishes an annual call for proposals in the Official Journal of the European Communities. However, the most sustainable solution would be for Estonia to become self-sufficient, sourcing funding from within the country. The private sector and supportive countries will also have a role to play in funding Estonia's national HIV/AIDS strategy.

What can Merck Sharp & Dohme do to help?

Merck Sharp & Dohme (MSD) has been present in Estonia since 1994 and has been anxiously watching the growing threat of HIV/AIDS in the country and the region.

As part of its corporate social responsibility, and based on its expertise in building public-private partnerships in the Americas and Africa, MSD has been collaborating with the Estonian government, representatives of the health sector and NGOs to help develop the 2006 - 2015 HIV Strategic Plan including an Action Plan for 2006-2009.

The overall objective of the strategy is to bring about a steady downward trend in the spread of HIV infection. This involves increasing people's awareness of how HIV is transmitted and reducing hazardous sexual behavior. Another aim of the plan is to improve the quality of life of those infected with HIV/AIDS and to make the necessary treatment available to them. The strategy aims to increase HIV/AIDS expenditure from the 2005 figure of 56 million kroons (Euros 3.6 million) to 400 million kroons by 2009. The rate of HIV infection in Estonia currently stands at 55 per 100,000 people. The plan is to reduce this number to 20 per 100,000 by 2015.

MSD is convinced that this goal can only be achieved by strengthening the links between the NGOs' social services and government health services.

This must occur within a partnership which is transparent, evidence and science-based, and which includes the monitoring and evaluation of the plan's implementation.

The Global Fund program ends in October 2007 and the WHO will do its recurrent National Plan assessment in that year too to monitor the implementation of the plan where both national and international community (WHO, UNAIDS and others) have contributed. The only hope for the thousands of Estonian HIV-infected people is that this new partnership supported by MSD will take up the reins and guide the country to a truly bright future.

NEXT MONTH: NGOs IN ESTONIA

Interviews, photos and article by S. d'Aurelle de Paladines, Editor : Fiona Hall.