Aiding the AIDS Fighters

Latvia’s experience suggests preventing the spread of HIV cannot be left just to the civil sector, argues a UNDP specialist. by Ilze Jekabsone 18 May 2005 RIGA, Latvia | There might seem little positive to say about the trends in HIV/AIDS in the Baltic states. In Estonia, the rate of infection is, at 1.1 percent of the population in 2003, above the 1-percent threshold at which the spread of the disease is expected to explode. In Latvia, it is 0.6 percent (though some estimates are higher, some lower) and it is spreading fast in the heterosexual population. Only in Lithuania is the disease at an untroubling level (less than 0.1 percent).

But Latvia does offer some positive news. For the past three years, the number of new HIV cases has been dropping each year by almost 30 percent (323 people joined the list in 2004). In other words, although the infection is now in the mainstream of Latvian society, its impact is being contained and reduced.

The most significant drop has been in the number of intravenous drug users contracting HIV, from 82 percent of all new infections in 2001 to 73 percent in 2002 and 57 percent in 2003. This understates the role drugs play in spreading the disease – use of non-injected drugs is rising and some of those heighten sexual appetite, which has contributed to the increase in the sexual transmission – but is nonetheless a dramatic improvement in what is, numerically, the most at-risk group in the country.

Part of the decline may be attributable to a new commitment to informing Latvians about HIV – but it also reflects what amounts to a breakthrough in the country’s approach to the problem of HIV/AIDS: the greater involvement of local governments. How this breakthrough was achieved says much about how the disease first became a problem – and the challenge of responding to an epidemic in a society in transition.

TURNING THE TIDE

1991 was, in many ways, Year Zero for Latvia. HIV/AIDS had begun to surface as a problem in the last months and years of the Soviet Union, but in the first years of independence the country had other battles on its hands. Central government had to plan a transformation of the country and try to maintain old systems while its revenues were tumbling; local government was acquiring new powers but had little money to deal with huge problems; and, like all post-Soviet countries, civil society had no recent history of public involvement.

The anti-AIDS effort suffered as a result. In keeping with the Soviet focus on medication, central government spent most of its HIV/AIDS budget on treatment and very little on prevention. Local government did almost nothing to treat or prevent HIV/AIDS; under the national policy, the state was supposed to forge partnerships with municipalities, but it allocated no specific funds. Those who were concerned about preventing the spread of the disease – supranational organizations (such as the UN Development Program [UNDP] for whom the author works) and programs run by other national governments – therefore looked to fledging nongovernmental organizations (NGOs) to work on prevention.

Donors made considerable efforts to build up civil society. Their help was crucial since the state provided no subsidies to NGOs (except sports groups). Public-private partnerships, another source of funding, produced little; dealing with HIV and high-risk groups is simply too unattractive, and sometimes too controversial for potential partners. So, when donors did not renew grants or could not cover all the costs, the NGOs working on HIV/AIDS and drug-related issues faded away.

The problem was that the system was uncoordinated and most of the prevention efforts depended on young, weak organizations whose financial health was vulnerable. NGOs filled a gap in an area under-funded by the state but, without public support, could not fill the gap in the long term.

In the meantime, rates of infection climbed. Most of the government’s budget for prevention was spent on information campaigns targeting the general public rather than specific groups. But playing on fears had only a limited effect, since many did not seem to feel fear. Even Olga, an intravenous drug user in the mid-1990s, was oblivious and unconcerned. “At that time there was no information about the possibility of getting AIDS from injecting drugs.” She recalls that, for her and her husband, “the HIV problem seemed to be far away – in Africa rather than here.”

But by 1997 the infection had begun to spread rapidly, after the first cases were recorded among intravenous drug users, of which Latvia had an unusually large number (40,000 in a country with a population of 2.3 million, according to police data from 2002). By 2001, the number of new HIV cases was almost twice as high as in 2000.

But, just as infection rates were accelerating, it also became clear that the prospects for grants were declining. Central government was unwilling and unable to fund the NGO operations.

Since 2000, there has been an effort to incorporate one key sector that earlier played next to no role in dealing with HIV: municipalities. In the 1990s, the local authorities’ role was largely restricted to granting permission to NGOs to operate, and – if the NGO was lucky – the free use of city-owned premises. In two or three cases, all in the capital Riga, local authorities also provided some money.

In 2000, the Latvian government and donors began talking with local governments where HIV and drug use are highest about setting up a small, pilot network of eight drop-in centers for high-risk groups, particularly drug users. Few local communities were willing to become involved. Drug abuse was not a priority for local officials; for them, unemployment, schools, and access to medical care were more burning issues. Nor were many of them willing to court unpopularity by becoming too closely associated with a disease shrouded in myths. Some communities objected to opening up needle-exchange programs; others objected to having counseling centers in their neighborhood.

But the drug users’ way of life meant that in any case this high-risk group called on local services at some point. Olga, who is no longer a drug user and instead works with them, describes the seasonal pattern. “Drug use decreases during the winter and spring, and then it increases again in summer,” she says, since “many users go to rehabilitation or treatment clinics during the winter because they have no income and sometimes no home.” There are other local costs, since many drug users are involved in crime of some sort.

It took a long time to convince local councils that action was needed and a year and a half for the project to start. Even the city with the second-highest HIV rate, Ventspils, was very reluctant to join the network of HIV prevention centers. The councilors did not want drug use to be seen as a problem in the city; it was therefore hard to convince them to invest in prevention or harm-reduction efforts. Many local officials initially found it hard to understand why a national program should not be paid in full by the national government. That was an attitude that also fed the notion that AIDS, a problem on their doorstep, was not in fact their problem.

AIDING THE AIDS FIGHTERS

What the program sets up is a system in which the local government (or, in Riga, an NGO) provides services aimed at prevention and the state in effect controls the quality of the service by coordinating the whole project and activities at the national level. Donors continue to play some role: their money is being used to expand the activities of the whole network and individual centers, which are otherwise limited to high-risk groups and providing information to the general public.

In effect, the program means that the various levels of government and the civil-society sector all have a responsibility – and, by contributing, they all have a sense of ownership in the project. This more decentralized system brings programs closer to the source of the problems. (In Jurmala, a famous seaside resort, the center has, for example, bought a minivan to take its service out onto the road into remoter areas.) A more coordinated system means that services are delivered to more communities, funds are shared out and allocated more efficiently, and trends in the spread of the disease are monitored better.

Olga, who has been raising awareness of AIDS issues among drug users for six years, believes the impact has been significant. In 2003, the center she worked in lost funding from its donor, but the municipality offered resources and the center continued as part of the HIV/AIDS prevention network. If it had not, “I can imagine that the number of HIV infections would be twice as high as now,” she says. “People would not know the risks. Yes, we had to move to another building, but that did not affect our work. Here, it is better now. We have more space and, with support from NGOs, we can offer tests, syringes, encourage people to take treatment and try to ease access to therapeutic medicines.” The response, she says, has been very positive.

Since the project went nationwide in 2002, 5,992 people have sought advice, tests, or needles from the centers (most have come back roughly 10 times).

The network is expanding (13 centers were operating by the end of 2004), but so too is the disease. The 3,113 families in Latvia affected by HIV still live mainly in large urban areas and along the country’s main transit routes, but HIV has now also reached small towns and remote districts. Even more than ever, prevention is a national task.