HIV@MSD - Fighting HIV/AIDS at the grassroots in Estonia

Facing the Facts: Estonia gets to grips with HIV

Reproduced with permission of REC, http://www.rec.org

NGOs (non-government organizations) play a critical role in supporting those affected by HIV/AIDS in Estonia. They have acquired considerable expertise at the grassroots over the years, working closely with those infected or affected by HIV/AIDS. Many have set up very successful programs to mitigate drug-related harm and provide daily support to people living with HIV/AIDS. The indisputable role that they play in the development and delivery of outreach prevention and support programs is vital in helping the government reinforce its efforts to stem the spread of HIV infection in Estonia's wider population.

The Global Fund has provided a good resource base for many of these NGOs until now, but with this international source of funding set to dry up in 2007, the future is looking rather uncertain.

There are four NGOs in particular which stand out from the crowd. Here they share their experiences with us and consider what the immediate future might hold for their way of working.

Narva Narkomaanide ja Alkohoolikute Rehabilitatsioonikeskus (NNARK) - "You will not be alone"

Kohtla Jarve NNARK was one of the first NGOs to start working with alcoholics (back in 1987) and with Intravenous Drug Users (IDUs). Since 2000, the spread of HIV/AIDS among IDUs has become so worrying that Tatjana Magerova, NNARK's Director, decided to open a harm reduction center in the north-east of Estonia; an area closer to St Petersburg than to the Estonian capital, Tallinn. In 2003, NNARK started a methadone treatment program along with various programs for HIV women and children, and for IDUs and families.

NNARK's 32 staff members include nurses and social workers working in six small centers dedicated to needle exchange and harm reduction programs funded by the Global Fund. Ten other staff members are based in NNARK's main center near the Narva Hospital. They include doctors, nurses, social workers and a psychologist, who together provide methadone detoxification and maintenance therapy, medical consultation and psychological support to IDUs and their families, as well as to HIV infected or affected people. Unusually for an NGO, and thanks to its good contacts with hospital departments, the hospital has given NNARK's in-house doctors permission to distribute ARV treatment to HIV-infected patients. The center also provides new syringes to IDUs as part of a needle exchange program. On average, 200 to 220 people visit this center each day.

Tatjana Magerova has seen positive results since the implementation of the methadone and needle exchange programs. These results are echoed in the local newspapers and disseminated by the NGO network for people living with HIV/AIDS (PLWHA) that she launched a year ago (she set up a second network for IDUs more recently).

"It is important to educate the population if we are to see changes in sexual behavior and a reduction in stigmatization. We work with PLWHAs to be sure that they will continue to come here to get proper medical and social support, and also to follow them up and eventually get work for them," she explains.

She goes on to describe how the patients visiting the center (probably the "easy part") are split into three groups:

"First we have the educated people who know where they are heading. They are the easy 35% to reach and educate on the risks of contracting sexual diseases like HIV and to explain the links with drug injection and the excessive consumption of alcohol. Then comes the 2nd group. These people don't know where they stand. They are sent to us by the hospital to get methadone therapy or methadone substitution therapy, to be convinced to stop using drugs and to be educated like the first group. These 55% definitely need our support. They are part of a "hospital emergency" program initiated with the Emergency Department of Narva Hospital. Finally comes the 3rd group; these people don't care at all about risk behavior. They represent around 10% of the total. These are the hardest to reach and it will take time before they can be included in any program".

Tatjana would like to start many other programs, but this depends on funding from the National Institute for Health Development. She is worried that all the NGOs will be financed solely by government after October 2007 when Estonia's funding from the Global Fund ends. How will the government cope with the increasing number of patients? What kind of budget will she get from the government to support the increasing number of patients who will come to NNARK? She is already seeking alternative funding to compensate for the loss of the Global Fund money, but it is not simple. The only certainty that she has is that funds will only come if she can show continuous, significant and visible results. Given her overwhelming energy, I wouldn't be surprised if we hear a lot more from this remarkable woman!

E-mail: rehabi@hot.ee , Tel: +37 256 452 814 / +37 235 48 344

The watchword of ALLIUM Center in Kohtla-Järve is 'partnerships'.

Kohtla Jarve This new NGO, launched in May 2005, focuses on harm reduction for drug users in the North-East province. It is contracted by the local government, the National Institute for the Health Development (TAI) and the Ministry of Social Affairs to supply statistics on the center's harm reducing activities, and on the behavioral trends among IDUs/alcoholics and HIV-infected people. Within a year, the number of 'visitors' (clients) per month has grown from 15 to 230.

"Reducing harm among drug users is our core mission" explains Vjatsleslav Akimov, the center's coordinator. "We aim to stabilize HIV, hepatitis B/C and TB among drug users; to reduce drug-related nuisance in the community, thus leading to a safer community; and to motivate our visitors to start treatment or to start rehabilitation. The center's staff successfully runs the needle exchange program and the one meant to assist drug users in getting all necessary documents, when they have lost them for any reason. Our visitors can get the qualified assistance of a psychologist, social worker and of a doctor. There are also support groups for HIV-infected people, to teach them how to become self-confident and autonomous."

Eighty percent of Allium center's 'visitors' are HIV-infected. All of them are in serious trouble (both in terms of their health and the law). They either come to the center to have a place to rest, drink coffee or tea, take a shower, or because they are accompanied by family members who worry for them. Others are sent to the center by the Central Hospital Emergency Unit, by the local police with whom Allium works closely, or by the local government's Criminal Care and Social Department.

Akimov feels that the organization's future in the coming two years is not as insecure as some of the other NGOs:

"In a way, we are lucky because we get our money for the everyday activities from the National Institute for the Health Development, the local government covers the expenses related to the management of our facilities and we don't have to worry for our survival. We recently benefited from the experience of six trained specialists in law, social education and medicine for a year through a program set up between the Estonian government and the Dutch Ministry of Social Affairs to share good practice and scale up our competencies." The center is guaranteed to remain operational until the year 2008, as per the obligations of the project participants".

Skill-building is a goal that Allium shares with the local government and the Ministry of Education, and it is Allium's role to teach local teachers and pupils about the danger of drugs, alcoholism and sexual diseases. As well as the 60 lectures given as part of their school prevention campaigns, Allium has asked 600 children aged between 15 and 18 in schools and 300 children of the same age in youth camps to fill in a questionnaire about HIV/AIDS. Parents were also surveyed. This revealed that most of them knew little about the HIV and hepatitis infection cycle, yet most of them had already taken one drug and were sexually active. These worrying findings were forwarded to the local government in June, as part of Allium's monitoring and evaluation responsibility. This includes alerting relevant government authorities to emerging trends and obstacles to the proper implementation of programs.

Allium's partnership with the Crime Department of the Ministry of Justice is also bearing fruit: "We are planning to open a center to work with alcoholics as a pilot project. Many crimes are due to alcoholism. A prison will be opened in the region within the next four years. At the moment the main prisons are in Tallinn and Tartu. Allium already works to establish contacts between the prisoners, their families and the social workers. Many current Allium 'visitors' have spent time in these prisons or will end up there."

After more than a year, Akimov feels his partnership approach is working well, but he'd still like to see better partnerships with educational and private companies to improve the quality of life for his visitors and to help them reintegrate into society. His ultimate goal is to 'network' all these partners together for better coordination and to exchange experiences. The Ministry of Social Affairs and the National Institute for the Health Development currently perform these tasks, among lots of other activities and duties. "If only there was an institution to link all local programs, we would have better results".

He identifies two major challenges at the national level: (1) the lack of consensus among politicians and government officials on how to rehabilitate these people back into normal life; and (2) the lack of a Sick Fund Card that would give Allium's visitors free access to government health services. Another concern is that at the moment it is impossible for him to follow-up his visitors, most of whom are anonymous. While there is a list for celebrating visitors' birthdays at Allium, it doesn't give any information on their identity and address.

"It is frustrating to see our visitors opening their hearts to our staff, then disappearing. Still, I know of 15 IDUs in Tallinn and five in Tartu who are doing well". On my way out, I see letters and drawings posted on the wall by the entrance. "One is from an ex-IDU who stopped taking drugs after visiting Allium. He has a job now, a new home and has just started a family. There is a way out for our visitors, it's just a matter of giving us the tools to show it to them".

E-mail: alliumcentr@hot.ee, Tel: +37 332 3230 / +37 505 4793

CONVICTUS Eesti

Estonia Julia Vinckler, Convictus's head, recalls the cold day in January 2006 when the outside temperature dropped to - 30°c. A penniless man arrived at Convictus in the evening, too late to find him a place to sleep in one of the usual homes. "There was no other solution than to pay for a hotel room". This is typical of the kinds of people who seek help from Convictus. They are usually HIV-infected drug addicts or suffering from hepatitis B/C; ex-prisoners or prisoners; people who have dropped out of school, and who are unemployed, Russian speaking and very often homeless.

Convictus Eesti was launched in Tallinn at the beginning of 2001. It is an offshoot of the Stockholm-based organization, the Convictus Bryggan Day Center. It currently employs 25 people dedicated to the following programs:

A large needle exchange and counseling program for IDUs (funded by the Global Fund)
A psychosocial support group for HIV-positive prisoners (funded by the Global Fund and the Ministry of Justice)
A psychosocial support group for HIV-positive ex-prisoners (funded by the Global Fund)
A support group for HIV-positive female drug users (funded by the Estonian Government)

Convictus helps the government to collect accurate statistics on intravenous drug use and on the health status, social situation and ethnic background of this particular group. They refer people to VCT centers for anonymous HIV testing, provide a needle exchange program to approximately 600 regular clients out of the 1800 visitors of the center, and offer soap and clothes to around 200 other people.

As well as its normal prevention activities, Convictus educates the general public about the risk of spreading TB and HIV in prisons. At present, the tuberculosis infection in prisons is many times higher than in the rest of the population. Earlier this year Convictus organized a roundtable on The Problems of HIV, TB and Hepatitis in Estonian Prisons, involving experts from the Tallinn Centre of Infectious Diseases, the Ministry of Justice, doctors working in Estonian prisons, the Open Society Institute (private foundation promoting human rights, economic, legal and social reforms), social workers and journalists.

Julia Vinckler is worried about how Convictus's activities will continue after October 2007. She doubts that all of them will be taken over by the government once the Global Fund has stopped financing her programs.

"Before we joined the European Union, getting money from international donors like the Global Fund was not too difficult, but now the budget for European countries has been cut by 40% and we cannot apply for support from the Global Fund anymore. We need guidance and support from other organizations such as our mother organization in Sweden, or from NGOs we are in contact with, in St Petersburg, Moscow and in Ukraine. If only we could get funds for three years instead of one year like now, we could better plan our support activities."

E-mail: Julia.vinckler@convictus.org, Tel: +372 5 341 0437

AIDS-I TUGIKESKUS

Estonia This AIDS information & support center was created in 1994 to provide social support and harm reduction services in Tallinn. A Tartu branch opened in 1995. AIDS-I Tugikeskus was the first NGO to start a program for commercial sex workers (CSW) in 1994, a needle exchange program and a methadone program in 1997, and finally the first program for rehabilitation of injecting drug users in 1998.

AIDS-I Tugikeskus has two offices in Tallinn:

The first provides testing facilities, medical services and sexual education on STIs for the general public, and HIV & STI prevention, safer sex education and medical services for commercial sex workers.
The second is dedicated to IDUs. It provides narcologist-psychologist consultations, needle exchange, methadone treatment and rehabilitation for drug users in a day care center, and in a home located in the country side

"We provide services to all groups of people: heterosexuals, IDUs, CSW, gays and lesbians, explains Jury Kalikov, the center's head. "In the last two years we have started two projects: one focusing on medical services here for sex-workers, and a drop-in center providing them with condoms, counseling and basic hygiene (showers, etc), funded by the Global Fund. However, the funding stopped suddenly for no reason. This leaves only me and 24 volunteers to run the center; I cannot contract specialists over the long term without sound and continuous funding. Therefore, I am considering approaching Norway to replace the Global Fund money".

From next year AIDS-I Tugikeskus, like all the other NGOs, will have to work much more closely with the government. They are apprehensive about this process and initial signs are not hopeful. This year, Jury Kalikov, along with 13 other Estonian NGOs, was invited for the first time to work with the government on its 2006 public health expenditures. Their first impression was that some funding areas appeared to be inappropriate and others were under-financed, so together the NGOs made many suggestions for improving the budget's emphasis. But the draft later circulated among the participants contained many changes from those the NGOs had all agreed during the roundtable discussion. Jury, like his colleagues in other NGOs, is puzzled. Incidents like these do not bode well for a smooth-functioning and trusting partnership between the NGO sector and the government in the coming years.

He feels the HIV budget is vitally important with the cessation of the Global Fund. And there are many areas which he would like to see on the government's agenda:

Commercial sex workers

"There is no state policy for CSWs, whose numbers are set to rise from 1,500 to 3,000 over the next five years. The government wants to emulate the Finnish and Swedish model whereby CSWs' customers are sent to jail. But this measure will not stop prostitution, it will simply hide it; CSWs will escape from the area of influence of social programs and it will be harder to counsel them and treat them if needed. The ultimate danger is that we will lose sight of the infection. Instead, we should intensify our efforts to keep this population closely monitored".

Rehabilitating IDUs

By law, NGOs are not allowed to give antiretroviral therapies to their methadone patients, although they know that it works. They have so far failed to convince the government that patients who can stay away from drugs long enough can gain self confidence, start treatment and eventually be reintegrated into society. Jury would like to see the government introduce new initiatives such as putting methadone patients on antiretroviral therapy as part of their rehabilitation program. In the meantime, NGOs will need to build bridges with the Infectious Diseases Departments of hospitals to treat their patients from A to Z, instead of referring the patients case-by-case as they do now.

Rising HIV among female partners

Another area of concern is the increasing number of young, well-educated women who have never used drugs, but who are being infected by their partners. For the first time ever last year, the number of young HIV positive women exceeded the number of HIV positive men. Many of these women are likely to pass the infection onto their babies before too long. This emerging sector is yet another blow to those who think that the HIV/AIDS epidemic is under control in Estonia...

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