The Courage to Reflect, Question and Commit – Speech by Michel Sidibé, Executive Director of UNAIDS at Fourth Conference on HIV/AIDS in Eastern Europe and Central Asia (Moscow, 12 May 2014)

Honourable Co-Chairs, Dr. Onischenko and Dr. Popova, dear colleagues, dear friends,

I am honoured to be in Moscow to open this important conference with my esteemed Co- Chairs, members of civil society and people living with HIV from across the region of eastern Europe and central Asia. I am pleased to join First Deputy Prime Minister Igor Shuvalov and Minister of Health Veronika Skvortsova, who are the most senior officials of the Government of the Russian Federation to ever address the EECAAC conference.

The presence of key leaders, civil society and partners sends a powerful signal that this is not just a conference, but an important opportunity to reflect on the transformative moment we are in. This conference comes just 600 days before the deadline for the Millennium Development Goals. It is time to take stock of our progress. This conference is an exceptional opportunity to have a forthright and frank discussion.

We are not here to talk about past regrets. We are here to shape the future of eastern Europe and central Asia—a future with zero new HIV infections, zero discrimination and zero AIDS-related deaths. This region is famous for passionate, people-led revolutions. We need a revolution in HIV prevention now. Combination prevention, including HIV treatment, must be at the centre of our response.

Across the globe, progress against AIDS has been amazing and inspiring. We have broken the trajectory of new HIV infections. Today, we have million people on life-saving treatment. Around the world, AIDS mortality is declining. We are making unprecedented progress to eliminate mother-to-child transmission of HIV by 2015 and keep their mothers alive.

The AIDS response has also revolutionized the paradigm on global trade and the Agreement on Trade-related Aspects of Intellectual Property Rights (TRIPS) to make generic drugs available as a global public good. The AIDS response has been an entry point to make once costly, life-saving drugs available to poor people. Just a decade ago, the cost of HIV treatment was US$ 10 000 per patient per year, and patients had to take 15 pills a day.

Today, we have fixed-dose combinations available for less than US$ 100 per patient per year in one pill. This progress, combined with other new scientific breakthroughs, is offering fresh hope that we will see the end of the AIDS epidemic.

Courage to reflect on difficult questions

So, as the world is beginning to talk about ending AIDS, our conference should have the courage to reflect on a few difficult questions I have brought to Moscow:

  1. After decades of effort and major financial investment from governments and partners, why does eastern Europe and central Asia still have the highest rates of new HIV infections and AIDS-related deaths, when we are seeing declines in other regions of the world, such as Africa and Asia?
  2. Why are injecting drug users still facing barriers to prevention and treatment, when they are the largest affected population in this region?
  3. Why is there antiretroviral coverage of only 30% of people living with HIV in eastern Europe and central Asia? Based on the new World Health Organization HIV treatment guidelines, this falls to only 16%. How is this possible when the majority of people living with HIV in western Europe have universal access to treatment?
  4. Why does first-line antiretroviral treatment in the Russian Federation cost as much as US$ 2500 per person per year, while other BRICS (Brazil, Russian Federation, India, China and South Africa) countries are paying less than US$ 100 for drugs that are domestically manufactured?
  5. And, finally, why is the Russian Federation the only country in the G20 and the BRICS where the HIV epidemic is still growing?

I know these are difficult questions. But we cannot be here in Moscow and not have this discussion.

People in need – not criminals

Allow me to share my thoughts on the way forward for this region.

The data show that the alarming increase in new HIV infections in this region is driven primarily by injecting drug use. Never in the history of the global AIDS epidemic has there been such a large and growing HIV epidemic concentrated within a community facing barriers to essential prevention and treatment services.

If governments want to prevent their citizens from getting sick and dying, they must ensure that people who inject drugs are not treated like criminals. They should be treated as people with an illness that needs prevention, treatment, care and support.

I was recently in China, where I met with the Vice-Premier to review the remarkable progress of their work on HIV prevention among injecting drug users. A few years ago, China enforced zero tolerance for drug use, and the HIV epidemic was growing quickly among injecting drug users. Today, China is implementing one of the largest methadone substitution programmes in the world. Within six years, over 385 000 patients were enrolled in 800 methadone substitution clinics. Today, new HIV infections among patients receiving methadone are close to zero. The data from China is bold and clear—harm reduction and substitution therapy are evidence-based programmes that save lives.

In 2014, eastern Europe and central Asia has two urgent priorities: to ensure that all injecting drug users have access to clean injection equipment; and to implement scientifically proven, evidence-based methods of drug treatment, particularly methadone, which can cost as little as US$ 85 per year. These interventions are essential to avoid a costly epidemic of HIV and hepatitis C.

Several countries in the region are already moving forward: Armenia, Azerbaijan, Belarus, Georgia, Republic of Moldova, Ukraine and several countries in central Asia are currently using harm reduction, including substitution therapy, to keep their HIV epidemics among injecting drug users under control. Some of these best practices will be presented at this conference; our duty is to ensure they are scaled up and sustained.

On the subject of harm reduction, I am very concerned about the situation in Crimea. As of March 2014, 806 patients were enrolled in a safe and effective substitution therapy programme there. Stopping this treatment violates the patients’ right to health. It will cause health setbacks and put their lives in danger—it will increase their risk of returning to illegal drug use, stopping their treatment for HIV and tuberculosis, and becoming infected with HIV and infecting their partners.

I call on the authorities of Crimea and relevant Russian institutions to ensure that these essential, life-saving services are not interrupted or suspended. This is not a political issue — it is a serious health matter. Their lives are hanging in the balance.

Civil society’s essential role

The impressive knowledge and unique expertise of civil society in this region is one of the most impressive in the world. It is more important than ever to support and develop these organizations and communities, which are often the only channels to reach people who are most at risk with life-saving services. As I said at the opening of the G20 Civil Society Summit last year in Moscow, we will never end AIDS without strong civil society networks.

But we are facing a major challenge in this region to ensure that no one is left behind. Reaching key populations must be moved to the top of our agenda.

Growing wave of criminalization

I am extremely concerned about the growing wave of criminalization in many countries in this region. These laws drive key populations—LGBTI people, sex workers, injecting drug users and others—underground. And when people are scared and hiding, they engage in even riskier behaviour. They do not access HIV education programmes. They hesitate to get tested for HIV. They do not use condoms. They cannot access HIV treatment.

This is why, after 30 years, HIV epidemics still persist in these groups all over the world. HIV flourishes anywhere marginalized people do not feel safe to access services. We will never end the AIDS epidemic by criminalizing or frightening the populations who are most affected.

It simply doesn’t work. Ending AIDS is not just about giving people pills and promises. We must protect their human rights and restore their dignity.

I also want to shine a spotlight on some of the significant progress we have seen in eastern Europe and central Asia.

In the last three years, countries in this region made commendable progress to end the transmission of HIV from mother to child. I expect this region to become the first in the world to reach the goals of no more babies being born with HIV by the end of 2015 and keeping their mothers alive.

I also want to congratulate the countries that have lifted HIV travel restrictions since the last EECAAC conference: Armenia, Republic of Moldova, Slovakia, Tajikistan, Ukraine and Uzbekistan. As I recently wrote to President Putin, restrictions on travel and residence of people living with HIV have no economic or public health benefit. I call on Belarus, Lithuania, Russian Federation and Turkmenistan—the last four countries that maintain these restrictions in this region—to remove them by World AIDS Day 2014.

It always seems impossible, until it is done

I know that what I am calling for today seem daunting. Let us remember what Nelson Mandela said: “It always seems impossible, until it is done.”

I call on conference participants to adopt a bold, visionary conference declaration that answers my most difficult questions. This conference must show to the world that this region is serious about halting this epidemic. We must strengthen international and regional cooperation to ensure our successes are scaled-up, sustained and expanded across the region.

I also want us all to remember that in 1958 the Soviet Union proposed to the world that smallpox be eradicated within 10 years. This led to one of the greatest global health victories of the twentieth century.

We cannot end the AIDS epidemic without the Russian Federation taking a decisive leadership role here in the Russian Federation, across this region and around the world.

Thank you.