BRITISH COUNCIL UKRAINIAN INSTITUTE FOR SOCIAL RESEARCH

This Project was implemented with financial support from the Department of International Development of the United Kingdom (DFID) and the British Council for the Government of Ukraine

THE SOCIAL AND ECONOMIC IMPACT OF HIV AND AIDS IN UKRAINE : A RE-STUDY

Olga Balakireva Alla Scherbyns’ka Yulia Galustian Yuriy Kruglov Olexander Yaremenko Ukrainian AIDS Centre at the Health Ukrainian Institute of Social Ministry of Ukraine Research

Nataliya Levchuk Volodymyr Onikienko Institute of Economy, National Council for Studying Productive Academy of Science of Ukraine Forces, National Academy of Science of Ukraine Lidiya Andruschak UNAIDS

In co-operation with international consultants

Tony Barnett, University of East Anglia, UK and Alan Whiteside, University of Natal, South Africa

Edited by Veena Lakhumalani, The British Council, Ukraine

14 Kyiv City - 2001

Contents

INTRODUCTION

Executive summary

Section 1. THE NATURE OF HIV/AIDS AND THE GLOBAL EPIDEMIC

Section 2. HIV AND AIDS DATA 2.1 HIV Data 2.2 AIDS Data 2.3 General conclusions

Section 3. METHODOLOGICAL APPROACHES 3.1. Concepts of Susceptibility and Vulnerability 3.2. Description of Models for Projecting the Development of HIV/AIDS Epidemic in Ukraine and Incoming Data 3.3. Projecting the HIV/AIDS Epidemic in Ukraine: main results

Section 4. UKRAINE AS A RISK ENVIRONMENT 4.1 Demographic Situation in Ukraine 4.2 Social and Economic Characteristics of the Contemporary Ukrainian Society 4.3 Attitudes to People with HIV and AIDS in Ukraine 4.4 Behavioural Factors Contributing to HIV/AIDS Epidemic 4.5 Bio-Medical Factors and HIV Susceptibility 4.6 Regressive Analysis of Influence of Regional Development Factors on HIV-Infection Prevalence 4.7 Conclusions

Section 5. DEMOGRAPHIC AND SOCIO-ECONOMIC IMPACTS OF HIV EPIDEMIC IN UKRAINE 5.1 HIV/AIDS Impact upon Demographic Situation 5.2 Families’ Vulnerability 5.3 HIV/AIDS Impacts upon Economic Activity of Population 5.4 Susceptibility and Vulnerability of Some Economic Sectors 5.5 Social Support and Social Security to HIV-Positive People

Section 6. PREPARADNESS OF THE HEALTH CARE SYSTEM TO DEAL WITH HIV/AIDS

Section 7. HOW TO ORGANISE AN AFFECTIVE RESPONSE TO THE EPIDEMIC?

APPENDIXES

15 INTRODUCTION

This work seeks to throw light on the scale of the HIV/AIDS epidemic in Ukraine and attempts to identify some impacts the epidemic might have in the social and economic fields. Evidence throughout the world shows that HIV/AIDS decreases average life expectancy, increases the demand for medical services and highlights the problems of poverty and inequality. The inter-relation between HIV and economic development is complex. On the one hand, the epidemic affects economic development, and on the other, the epidemic development is dependent, to a large extent on the economic situation. This report focuses on the groups of population most vulnerable to HIV and attempts to identify the factors contributing to susceptibility to the virus. The epidemic is not limited to a certain community any more, it is spreading rapidly. Ukraine is becoming a society at a high risk of vast masses of the general population becoming infected. Today, it can be said that HIV threatens the future of the nation. This study has undertaken in order to analyse the social and economic context of the HIV/AIDS epidemic and to project possible demographic, social and economic impacts of the epidemic. As part of this research, projections were prepared to assess the scale of the epidemic years ahead in order to see its possible impacts. The projections presented are worth considering by health policy makers, especially in the field of HIV/AIDS prevention and dealing with demographic, social and economic effects of the epidemic. Ukraine became a sovereign country in 1991 with the population estimated at 49,036,500 on January 1, 2001.1 The first HIV case was registered in 1987, while 1994 is regarded as the first year of the epidemic. Between 1987 and 2001, 43,600 persons were infected.2 2,907 Ukrainians were diagnosed with AIDS, 1,473 died.3 Most of the infections are caused by intravenous drug use and unprotected sex. Unlike in comparable countries, the heterosexual epidemic overshadowed the homosexual epidemic - the registered of number homosexually transmitted infections are very few. The percentages of cases caused by unprotected sex and drug injection have changed recently. Throughout the last four years, the proportions of infections caused by intravenous drug use decreased from 83.6% (1997) to 56.6.% (2001) of the total, while the percentage of heterosexually transmitted infections grew from 11.3% (1997) to 26.9% (2001). The statistics on mother to child transmission are alarming: 196 cases were registered in 1997 (2.2% of the total) while 914 cases (13.1%) in 20014. Experts in the field believe the governmental statistics do not reflect the real situation. The estimated number of HIV infected in 1999 was 200000-240000 5. As in many other countries, the HIV epidemic in Ukraine is not a purely medical problem. The HIV/AIDS impacts might be classified as demographic (mortality and the number of orphans increase, while birth rate and population drop) and socio-economic at the levels of individuals, households, industry and the macro-economy. At the same time, it is important to remember that HIV is not a global catastrophe, it is rather an additional problem that unfolds like many others. A comprehensive multi-disciplinary approach is obviously needed to respond the HIV epidemic effectively. This message is addressed to everyone responsible for implementation of the Ukrainian National Programme on Combating AIDS, decision makers at the national and local levels responsible for HIV prevention, improving the surveillance system and providing HIV positive

1 Source: the State Statistics Committee of Ukraine (data available by January 1, 2001) 2 Source: Information Bulletin of the Ukrainian National AIDS Centre at the Health Ministry of Ukraine –No.21 – 2001. 3 Source: Information Bulletin of the Ukrainian National AIDS Centre at the Health Ministry of Ukraine –No.21 – 2001 4 Source: Information Bulletin of the Ukrainian National AIDS Centre at the Health Ministry of Ukraine –No.21 – 2001. 5 Source: HIV/AIDS Epidemic in Ukraine: assessment of the current situation/ The Project «Strategic of National Response to the epidemic of HIV/AIDS in 2001 – 2003» – Kyiv, 2000, p. 4. 16 people with medical aid and social support, as well as all governmental agencies and NGOs in the field of dealing with the epidemic. It is also addressed to the mass media and the society as a whole. The first attempt to postulate HIV/AIDS impacts upon the Ukrainian economy and society was a research study conducted in 1997 by Alan Whiteside (Health Economics and HIV/AIDS Research Division at the University of Natal, Durban) and Tony Barnett (School of Development Studies, University of East Anglia, Norwich). The research did not cover issues of medicine or epidemiology. It has endeavoured to project long term social, economic and demographic effects of the epidemic. The findings appeared to be of great importance for senior officials in Ukraine’s health care. The research provided for two scenarios: according to one, the epidemic would develop slowly as in West Europe, while according to the other, Ukraine might suffer from an explosive spread of HIV, similar to South East Asia. Projecting the epidemic and its impacts is a vital component of strategic planning of an effective response to the HIV/AIDS epidemic . Four years have passed since then. These years have been marked with significant social and economic changes in Ukraine. The situation with HIV definitely worsened. A law was adopted On Introduction of Changes to the Law of Ukraine on AIDS Prevention and Social Protection of Population (March, 1998). This period was marked with further development of civil society, including the non-state sectors in the economy, political parties, various NGOs and volunteer organisations. A variety of social projects and programmes have been launched, especially at local level. The general public attitude to people with HIV and AIDS has become much more tolerant. Throughout 2000, an assessment of the HIV situation and resources available to deal with the epidemic was conducted within the framework of a national campaign for strategic planning of a national level response to the epidemic for 2001-2003. The assessment was initiated by UNAIDS and run by the Ministry of Health Care of Ukraine. This study involved experts from many ministries, state agencies and research institutions. On July 11, 2001, a national programme of dealing with HIV/AIDS was adopted and on June 22, 2001, President Kuchma signed a decree, proclaiming 2002 ‘the year of combating AIDS’. Taking into consideration the recent changes, a new projection of the epidemic and its possible social and economic impacts is required.

We wish to express our gratitude to: Veena Lakhumalani, The British Council in Ukraine Chris Desmond, University of Natal, Durban, South Africa S. Philipovich, and L. Bochkova, Ministry of Health of Ukraine

Many thanks go to the research advisers: Tony Barnett, University of East Anglia Norwich, UK Alan Whiteside, University of Natal, Durban, South Africa V. Steshenko, Economics Institute at the National Academy of Science of Ukraine for the help and support in preparing this report.

We also would like to thank Sergei Naboka, the translator, and our colleagues from the Institute of Social Research: M. Varban, N. Dudar, I. Demchenko, D. Dmytruk, N. Karavaeva, and T. Bondar.

17 Executive Summary

20 years after the first case was registered, the HIV/AIDS epidemic has become one of the most serious problems affecting individuals and societies. The epidemic has touched all countries and its effects are more serious than it was predicted. Evidence throughout the world shows that HIV/AIDS decreases average life expectancy, increases the demand for medical services and highlights the problems of poverty and inequality. The inter-relation between HIV and economic development is complex. On the one hand, the epidemic affects economic development, on the other hand, the epidemic development is dependent, to a large extent, on the economic situation. As in many countries, the HIV epidemic in Ukraine is not a purely medical problem. The HIV/AIDS impacts are demographic (mortality and the number of orphans increase, while the birth rate and population drop) and socio-economic at the levels of households, companies, sectors and the macro-economy6.

· The present situation According to the data of the Ukrainian AIDS Centre at the Health Ministry, the first HIV case was recorded in 1987, while 1994 is regarded as the first year of the epidemic in Ukraine. Between 1987 and 2001, 43,600 persons were infected. 2,907 Ukrainians were diagnosed with AIDS, 1,473 died. Most of the cases are caused by intravenous drug use and unprotected sex (unlike in other comparable countries, the heterosexual epidemic overshadowed the homosexual epidemic - the registered number homosexually transmitted infections are very few). However, the importance of these transition modes have been changing through time. Throughout the last four years, the proportions of infections caused by intravenous drug use decreased from 83.6% (1997) to 62.5% (2000) of the total, while the percentage of heterosexually transmitted infections grew from 11.3% (1997) to 22.9% (2000). The number of mother to child transmissions is increasing: 196 cases were registered in 1997 (2.2% of the total) and in 2001, it was 937 (11.7%). Experts in the field believe that the governmental statistics do not reflect the real situation. The exact number of infections in Ukraine remains unknown. We estimate it to be 330-410,000 by 2001, that is not less than 1% of the adult population. According to the surveillance data, the groups at higher risk of acquiring HIV are intravenous drug users, patients with STIs, female sex workers, and men who have sex with men. However, the epidemic is not limited within a certain community any more, it is spreading rapidly. Ukraine is becoming a society at high risk of numbers of the general population becoming infected. Today, it can be said that HIV threatens the future of the nation.

6 The first assessment of the HIV/AIDS impacts upon the economy and society of Ukraine was the research “HIV/AIDS Socio-Economic Impacts in Ukraine” conducted, conducted in 1997 by Alan Whiteside (Economic Research Unit, University of Natal, Durban) and Tony Barnett (School of Development Studies, University of East Anglia, Norwich). 18 The most affected regions are those in the east and south: Dnipropetrovsk, Donetsk, Odessa, Mykolaiv and the Crimea Autonomous Republic. These are the ones marked with the highest level of intravenous drug use and HBV, an infection transmitted through the same channels as HIV. The age group of 20-39 years is most affected amongst both men and women. It is in this age group most of the cases are detected. From 1995 to the present, the epidemic was at the concentrated stage, when the prevalence rate equalled or exceeded 5% in at least one risk group, yet remained less than 1% among pregnant women in urban areas. Despite this, the analysis shows that the epidemic is at a critical juncture . Will society be able to respond the epidemic effectively and slow it down? If not, the epidemic will enter the generalised stage i.e. affect vast masses of the general population. The epidemic develops in a particular social environment and under the influence of certain “macro-factors” (the economic decline, rate of social cohesion in society, culture, religion, etc.), the socio-economic environment, behavioural factors (sexual practices, drug injection and personal hygiene) and bio-medial factors (type of the virus, stage of infection, presence of STIs, and gender). An important finding of this research was that it proved the hypothesis of a strong influence from the socio-economic factors upon the epidemic by region. An attempt has been made to describe the demographic, economic and social situation in Ukraine, in the context in which the epidemic develops: · The contemporary demographic situation is marked by population ageing, high dependency rate, (especially in rural areas), low fertility, and a sharp increase in mortality – all show a rapid “depopulation” of the nation. In general the demographic situation increases the society’s susceptibility, and vulnerability to HIV. Demographically, the nation is in decline. · The last decade in the history of Ukraine as a sovereign state was marked by a deep crisis in practically all spheres of life, income differential, inequality, impoverishment, active migration and budget deficit. · The shifts in sexual behaviours of young people, such as younger age of first sexual intercourse, a more tolerant attitude to pre-marriage sex, free access of underage people to pornography become especially important in the context of the HIV/AIDS epidemic in Ukraine. · At the moment, the inter-relation between AIDS and tuberculosis has become an acute issue. HIV/AIDS increases the risk of TB considerably. Obviously, the role of AIDS in the TB spread and TB mortality will grow. The presence of STIs increases the risk of HIV 5-6 times.

This makes Ukraine a risk environment, as the demographic crisis and the socio- economic situation increases the possibilities of the infection spreading amongst the general population and, at the same time, decreases the society’s potential to deal with the epidemic. The inequality between regions in Ukraine might lead to a situation when some areas will be affected worse than other due to unfavourable social and economic situation there.

· Projecting the epidemic The research group attempted to project the situation with the spread of HIV/AIDS in Ukraine in order the see potential impacts of the epidemic. That was done using the “Spectrum” computer programme ( the full name is “Spectrum Policy Modelling System”) developed by experts of the Future Group International. According to the optimistic scenario, the number of HIV positive people will exceed half a million by 2010 (582,000), the number of new AIDS cases will reach 44 360, and the number of deaths – 43 400. The situation will require more investment in the response strategies, there will be a greater need of hospital beds, the attendance of medical establishments will increase, etc. By 2010, the population will be 45,090,000 (45,480,000 without AIDS). According to the pessimistic scenario, the number of HIV cases will reach 1,440,000 by 2010, the number of new AIDS cases will be twice as high as the one assumed by the optimistic 19 scenario (95,210 people), while the disease will kill 89,200 people. The total size of the population will decrease to 44,890,000.

· The epidemic’s impacts As the epidemic cannot be stopped “instantly” the economic, demographic, and social impacts of it will develop through time and affect the future generations. A specific aspect of this disease is that even with effective prevention slowing down the pace of the epidemic, the number of illnesses and deaths will increase throughout the next several years. The epidemic’s impacts will manifest themselves at the levels of individuals, households, regions, branches and the whole nation. It means the epidemic will affect individuals, families, working teams, regions, particular sectors of the economy, labour market, health care system, social infrastructure, the system of social protection, and the administration system; it will have effects upon the level of social tension is society, demographic policy and national security.

Loss of income and impoverishment The epidemic’s impact on individuals is that people become infected, fall ill and die. At the same time, this will affect families. The illness of a family member will mean the loss of his/her input to housework and family budget and an increase in the family’s spending on medical services and medicines, as well as distraction of other family members from work or study as the ill family member will need additional care. Death of the bread-winner will affect poor families most.

The problem of orphans One of the epidemic’s effects will be an increase in the number of orphans, which might, in turn, increase the number of families consisting of elderly members and their grandchildren. The state will have to spend more for those children’s education, professional training, socialisation and providing them with accommodation. Considering that these children will lack parental care, they will be at higher risk of marginalisation. Another issue might be children rejected by their parents because of their HIV status. Impacts upon particular branches of economy and productive population

The HIV/AIDS epidemic is not limited by any boundaries or borders; it spreads across all levels and affects all economic sectors. The age structure of people with HIV and AIDS demonstrates that the economy loses the most productive and qualified workers. Older personnel are not capable of replacing young, since their educational and professional level is lower; at the same time younger staff lack experience that the old workers have. The main factors of HIV vulnerability in economy are: the absence of an employee from workplace due to illness or other reasons related to the disease (like care for an ill family member or attendance of a funeral), death of employees, negative emotional state of employees (fear of getting AIDS, losing colleagues, etc.), disturbed situation at a workplace; discrimination of HIV-infected people, additional loads on employees due to loss of personnel; loss of qualified labour force; decrease in expenditures for recruiting and educating additional labour force; falling quality of labour and its productivity; increase in cost of labour force; increase in the cost of medical services, insurance, handicap compensations, etc.; difficulties with scheduling and management of working process; difficulties with terms of work; tense relationship between employees and employer. The spread of the HIV/AIDS epidemic will affect different sectors of the economy differently. One might expect a re-distribution of labour force by branch. At the level of enterprise vulnerability will manifest itself depending on the quality of labour force that leaves the labour resources. Training of mangers and qualified workers requires

20 time, skills and experience. This means that the cost of recruitment, training, and social insurance (including medical) of the labour force will increase. The main social problems of people with HIV are: confidentiality of the HIV test result; relations with family members, relatives, and friends; relations with colleagues at work, greater possibility of losing job ; living conditions, finance; lack of legal protection and relations with the state and agencies bodies; discrimination and stigmatisation; access to medicines and medical aid in general; financial and physical help from individuals, organisations and services. The problem of HIV-positive babies that are left without parental support remains unsolved. Therefore, the needs of those infected with HIV or live with AIDS are not confined to problems with medication and medical care. They also need social support and protection from the society. This requires development of an integrated strategy for supporting HIV-positive people. Public opinion Most Ukrainians are aware of the existence of HIV/AIDS. At the same time, there are many myths about the modes of transmission, prevention, testing etc. This explains the hostility towards HIV infected people. Many Ukrainians would prefer not to deal with HIV infected people in every day life.

Health care system The current situation of health care system (financial instability, reduction in free medical provisions combined with limited possibilities of the health establishments to earn money, the recently imposed tax on profit from rent, etc.) makes it unprepared to deal with the epidemic in Ukraine. The public health sector will be the first to face the effects of the epidemic. An increase in the demand for medical services will be the first issue. Moreover, the AIDS related services will be just an additional burden for the system already failing to provide adequate medical aid the nation. The question is how many people will fall ill and to what extent the existing health care system will be able to help them. AIDS is an extremely expensive problem. In Ukraine, the yearly treatment course costs about $ 8-10,000. Whatever scenario becomes true, there will be an explosive increase in spending for: HIV diagnostics; treatment and care for patients with HIV and AIDS; treatment for opportunistic infections associated with AIDS; prevention of vertical transmission; prevention among risk groups. There will be an increase in the demand for adequately trained medical staff, testing centres, test kits, “anonymous testing units”, clinics, social service centres, services for psychological support and rehabilitation, education programmes and training curricula on HIV and safer behaviours.

THE RESPONSE TO THE EPIDEMIC: an adequate understanding and proper analysis of the short, medium and long term impacts will form a basis for effective strategies aimed at mitigation of these impacts and responding to the HIV/AIDS epidemic.

What has been already done Throughout 2000, an assessment of the HIV situation and resources available to deal with the epidemic was conducted within the framework of a national campaign for strategic planning of a national scale response to the epidemic for 2001-2003. The assessment was initiated by UNAIDS and conducted by the Ministry of Health of Ukraine. This study involved experts from many ministries, state agencies and research institutions. On July 11, 2001, a national programme of dealing with HIV/AIDS was adopted within the framework of the strategic plan. Currently, over 100 NGOs operate in the field of HIV prevention targeting both risk groups and the general population, particularly young people.

21 On June 22, 2001. President Kuchma signed a decree, proclaiming 2002 ‘the year of combating AIDS’. What do we have to do to respond effectively? · First of all, the society must accept the fact that the problem does exist. It is important to understand that the impacts of the epidemic are not a purely medical problem: they will have effect upon most of the economic and social sectors. · Second, it is necessary to understand the specific aspects of the epidemic. · Third, efficient systems of data collection need to be developed with regard to the epidemic. What is also required is an improvement in the system of sentinel surveillance with its essential component – behavioural surveys. A more effective system for case registration and database should also be established. · Fourth, thought must be given to the long term effects of the epidemic and ways to mitigate the epidemic’s effects.

To organise an effective response to the epidemic, the society should take the response strategy as a priority. Such a strategy will include: (1) effective solutions for HIV/AIDS diagnostics and treatment; (2) effective prevention strategies at the national level; (3) political solutions in the fields related to the epidemic. This will require appropriate steps to be undertaken by the whole society. It is important to realise that the problem is complex and thus needs a complex solution based on an inter- sectoral approach. This will require joint action from the state, private sector and civil society. This means that the society should ACT NOW.

22 SECTION 1. THE NATURE OF HIV/AIDS AND THE GLOBAL EPIDEMIC

The Nature of HIV/AIDS HIV infection is an infectious disease caused by the Human Immunodeficiency Virus (HIV) that slowly and irreversibly destroys the immune system to the point where people fall ill with malignant tumours or fatal opportunistic infections. At this point they are said to have the Acquired Immunodeficiency Syndrome (AIDS).

How HIV works HIV is a retrovirus, it is also a ‘slow’ virus. The virus cannot multiply independently as its genes contain RNA only (DNA is absent). Thus to multiply, the virus needs the DNA of the host cell. In fact the virus attacks two particular sets of human cells: one provide them with a safe shelter, hiding the virus from the body’s immune system and thus making it invulnerable to the antibodies. The others are CD4 cells, which organise the body’s overall response to foreign bodies. The virus uses these for multiplication. Once the virus attaches itself to the cell’s surface it penetrates the wall. Inside the cell, it copies its RNA into DNA. Once this has happened the cell starts to produce the HIV virus instead of antibodies. Eventually the cell dies. Although the body continues to produce new immune cells, the infected cells produce the virus which, in turn, infects more cells. Eventually the virus is able to destroy the immune cells more quickly than they can be replaced. At this point, new opportunistic infections begin to occur (malignant tumours, pneumonia, herpes, tuberculoses, funguses), infections which uninfected people would normally fight off. The Acquired Immunodeficiency Syndrome (AIDS) is the infection’s last stage. It might last from a few months to 2-3 years. This stage is marked by severe damage to the metabolism and increases in severity and frequency of the infections until the person dies 6. The first AIDS cases were diagnosed in 1981 in the USA. During the next two years, the general picture of the disease became relatively clear, the virus was discovered, its targets in the human body were identified7 and the first testing systems were developed. By 1983, the HIV virus had been identified.

Modes of transmission There are three ways the virus can be transmitted, yet probabilities of infection differ.

1. Sexual transmission – the infection is a result of unprotected vaginal or anal sex. 2.Blood to blood transmission – the virus transmits through infected blood or blood products, including use of contaminated needles, other medical instruments, intravenous drugs, donated blood or organs 3. Mother to child (vertical) transmission – the infection gets transmitted from mother to child during pregnancy, delivery or breast-feeding.

According to the Ukrainian National AIDS Centre, between 1987 and 2000, the epidemic trends as well as the main modes of transmission have been changing radically:8 - 1987 – 1994 – heterosexual transmission prevailed; - 1995 – 1998 – intravenous drug use through sharing of contaminated needles became the main mode of transmission; - 1999 – 2000 – heterosexual transmissions increased, the number of infected women grew as well as the number of children born with HIV. More women became infected in the last stage, which, in turn, increased the number of children born with HIV. In fact, Ukraine currently faces three ‘sub-epidemics’: an explosive one

6 Source: «HIV Infection: Symptoms, Diagnostics and Treatment. Guidance for Interns»- Lviv City, 2001. p. 3 7E.E. Kobets, Yu. V. Kobyscha, T.V. Papushin, «On AIDS», 1994, Kyiv City, p. 3 8 A. M. Scherbinska, «AIDS: Problems and Perspectives. HIV Infection: the variety of aspects» , 2001 ?yiv City, p. 17. 23 among IDUs; a slower yet mass heterosexual one, and, consequent to these, a rise in mother to child transmission.9

Groups at higher risk Among the general population there are groups at higher risk of acquiring HIV. These are intravenous drug users, sex workers, men who have sex with men, people with STIs, and prisoners. The available data on the risk groups are sufficient to identify the HIV situation in these groups, which, in turn, helps the analysis of the epidemic among the general population. Its development largely depends on the proportion of each group in the general population as well as how strong the social ties between various groups might be.

Stages of Epidemic To have a better understanding of the HIV situation in Ukraine, it might be helpful to look at the classification of the epidemic stages offered by the UNAIDS and the WHO. They identify three stages of the epidemic: nascent, concentrated and generalised. These might be described as follows (Guidelines for Second Generation HIV Surveillance, WHO/UNAIDS, 2000, p.24):

Nascent: HIV is less than 5% of all known sub-populations presumed to practise high risk behaviour (intravenous drug users, sex workers, men who have sex with men).

Concentrated: HIV prevalence is equal or above 5% in one or more sub-populations presumed to practise high-risk behaviour; yet under 1% among pregnant women in urban areas.

Generalised: HIV prevalence among pregnant women is above 1%.

In Ukraine, between 1987-1994, the epidemic remained at a nascent stage. From 1995 to the present, the epidemic was concentrated. The HIV prevalence among intravenous drug users in the cities of Mykolaiv and Odesa increased from 1.5% to 50% and 30% respectively within six months. The sentinel surveys conducted in 2000 showed the HIV prevalence to be at 42% in Poltava City, 40% in Donetsk City, 27% in Simferopil City and 18% in Kharkiv City. According to the governmental statistics, the average prevalence among IDUs is 8-10%10. The situation in the general population might be roughly estimated based on the data obtained from sentinel surveys among pregnant women (0.17% in 2000).

The Global Epidemic Throughout the 20 years of its entire history, HIV has been one of the most acute problems for many countries. The epidemic hit several countries and its effects appeared much more severe than expected. The experience of dealing with the epidemic world-wide allows an analysis of the impacts of HIV/AIDS, the main losses around the world the epidemic caused so far, and a projection of the future of particular countries in the context of the epidemic. According to the UNAIDS and the WHO11, by the end of 2001, the number of people living with HIV/AIDS was 40 million, which is 50% more than the number predicted by the WHO ten years ago. In 2001, 5 million new cases of HIV were registered, including 1.1 million women and 580,000 children under 15 years of age. There was an estimated 3 million adult and child deaths in the same year. In 2001 every day about 14,000 people contracted HIV, including 6,000 women. The epidemic is not the same all over the world. Table 1.1 below shows some trends in the epidemic by region.

9 Source: same as above, p. 17. 10 HIV/AIDS Surveillance in Ukraine (1987-2000), Kyiv, 2000, p. 13. 11 UNAIDS/WHO, «Development of the AIDS Epidemic: the situation by December, 2000», 2000 24 Western Europe12 In Western Europe, the overall incidence rate of AIDS was 25 cases per million population, approximately 8 times higher than in Central and in the Eastern Europe. Between 1996 and 2000, AIDS incidence in the area as a whole decreased at the overall annual rate of 28% among homo/bisexual men, at a similar rate among injecting drug users (-26%), and less markedly (-13%) among persons infected through heterosexual contact. However, in many countries HIV reporting data are limited to some regions (like in Italy or Spain). Substantial decreases in vertically acquired HIV cases reflect the success of preventive interventions implemented in many countries, in particular the UK.

Central Europe Central Europe has been relatively spared by the epidemic. The overall AIDS incidence (3.5 cases per million population) and the overall rate of newly diagnosed HIV infections (7.3 cases per million population) remained low. Paediatric cases (under 13 years) represent 29% of HIV cases reported in 1997-2000, which might be seen as a result of prevention strategies.

Eastern Europe In Eastern Europe, the rate of newly diagnosed HIV infections reported in 1999 (104 cases per million population) was more than twice that in the West and around 14 times that in the Centre. IDUs represent more than 62% of all newly diagnosed infections. In this group, numbers of reported cases increased by 60% between 1998 and 1999, while in the first six months of 2000 almost as many cases were reported as in the whole of 1999.

12 HIV/AIDS Surveillance in Europe. –Mid-year report 2000. –N63. –p. 7.

25 Table 1.1 Regional HIV/AIDS Statistics and Features, December, 2001 Adults and Proportion of Epidem Adults and children Main mode(s) of children Adult prevalence HIV positive Region ic newly infected with transmission for adults living with rate adults who are started HIV living with HIV/AIDS HIV/AIDS women Late ’70s – Sub-Saharan Africa 28.1 million 3.4 million 8.4 % 55 % Hetero early ‘80s North Africa and Late ‘80s 440,000 80,000 0.2 % 40 % Hetero, IDU Middle East South and South East Late ‘80s 6.1 million 800,000 0.6 % 35 % Hetero, IDU Asia East Asia and Pacific Late ‘80s 1 million 270,000 0.1 % 20 % IDU, Hetero, MSM Late ’70s – Latin America 1.4 million 130,000 0.5 % 30 % MSM, IDU, Hetero early ‘80s Late ’70s – Caribbean 420,000 60,000 2.2 % 50 % Hetero, MSM early ‘80s East Europe and Early ‘90s 1 million 250,000 0.5 % 20 % IDU Central Asia Late ’70s – West Europe 560, 000 30,000 0.3 % 25 % MSM, IDU early ‘80s Late ’70s – North America 940,000 45,000 0.6 % 20 % MSM, IDU, Hetero early ‘80s Australia and New Late ’70s – 15,000 500 0.1 % 10 % MSM Zealand early ‘80s TOTAL 40 million 5 million 1.2 % 48 %

14 The Countries of the former USSR In many ex-Soviet republics fall in living standards, unemployment, and other effects of social and economic crisis contributed to the increase in intravenous drug use and commercial sex, which, in turn, fuelled the spread of the virus. In the last few years, the number of infections increased dramatically in the CIS states, where between 1997 and 2000 the rate doubled. This specifically refers to the Russian Federation and Ukraine. The HIV/AIDS epidemics in Russia and Belarus is alarming: by the end of 2000, there were 70,000 and 2,000 registered cases respectively, yet the number of people with AIDS is still relatively low. Injecting drug use is responsible for most of the cases in these countries. Today, the epidemic in Russia is spreading more rapidly than in Africa. The cities of Moscow and St. Petersburg and Moscow and Irkutsk oblast are worst hit13.

Ukraine Ukraine is currently the epicentre of HIV in Eastern Europe. Governmental statistics show that the epidemic started in 1987. According to the Ukrainian AIDS Centre at the Health Ministry, between 1987 and 2001 43,600 HIV cases were officially registered, including 2,962 children. 2,907 adults and children were diagnosed as having AIDS, 1,474 persons died. The average HIV rate increased dramatically in 2001 as compared with 2000. By the end of 2001, it was 88.5 cases per 100,000 population14.

From the above it may be concluded that: § During the 20 years of its entire history, HIV/AIDS has developed into one of the most dangerous pandemics. Its scale exceeds all projections made by the WHO when the epidemic began. § Africa is the worst hit continent. About 90% of all infections are found there. Heterosexual form of transmission prevails. While it is true that Africa has until now been the worst affected world region, there is now evidence that in the FSU in general and Ukraine in particular, there is a threat of a very serious heterosexually transmitted epidemic. Evidence suggests that this has already progressed beyond the stage where prevention is the only response and governments and politicians must take very seriously the probability of a generalised heterosexually transmitted epidemic. This requires (a) major intervention programmes to encourage people to change their sexual behaviour and (b) serious consideration of policy options to confront the medium and longer term social and economic impact of the epidemic as it affects medical facilities, skilled people, households and state provision in general. § Europe contains some 500 000 people with HIV. Spain, Italy and France in the West and Russia, Ukraine and Poland in the East are worst hit. Most of the cases in these countries are associated with unprotected sex and drug use by injection.15 § HIV/AIDS has become a national problem in Ukraine and calls for an urgent response that should involve the wider public and learn from international experience in the field.

13 A. M. Scherbinska, «AIDS: Problems and Perspectives. HIV Infection: the variety of aspects» , 2001 ?yiv City, p. 16. 14 Source: same as above. 15 Source: same as above. 15 SECTION 2. HIV/AIDS DATA

2.1. HIV Data This section contains a review of the epidemiological situation in Ukraine. It presents governmental statistics provided by the Ukrainian AIDS Centre and the Health Ministry of Ukraine and points at some of the gaps in the data. Apart from the HIV prevalence in the general population, the situation in particular risk groups, such as intravenous drug users, patients with STIs, female sex workers, men who have sex with men is also examined.

SOURCE OF DATA AND METHODS OF DATA COLLECTION

Epidemiological surveillance is the main instrument of collection of data on infectious diseases, including HIV. It includes a system for collection, analysis and interpretation of data and regular reporting. The epidemiological surveillance system has proved to be effective for most infectious diseases. However, practical experience shows that the data provided by routine surveillance do not reflect the actual situation with HIV/AIDS due to the disease’s specific features, both medical and non-medical. This explains the need for finding better approaches of assessing HIV prevalence and the scale of the epidemic. A new surveillance strategy provided by sentinel surveillance has a good record in evaluating the epidemic scale in a number of West European, African and Asian countries. In Ukraine, although routine surveillance exists as a state programme, there is no single strategy. Local strategies are being developed at the regional level within existing financial constraints. Sentinel surveillance does not represent a uniform system and is being conducted intermittently in some regions. At the moment, behavioural surveillance is being introduced as an additional component of the HIV data collection. It includes monitoring of risk behaviours associated with HIV using STI data as indicators of behavioural changes. Behavioural surveys might cover the general population and/or groups at higher risk of HIV infection.

The system of epidemiological surveillance16.

HIV/AIDS Surveillance and Case Registration

Following the registration of the first HIV cases in 1987, an HIV/AIDS surveillance system was put in place in Ukraine. Official reports on the number of HIV examinations and detection of HIV/AIDS infection/disease cases became the first surveillance instrument. Identifying HIV infection is based on detection of antibodies to HIV in the blood serum sample under examination. The bulk of data is provided by screening blood donors, pregnant women, drug users, STI cases, as well as individual diagnostic cases. Currently 125 laboratories in Ukraine are engaged in HIV screening tests. They are located at blood transfusion centres, regional and municipal sanitary and epidemiology centres, AIDS prevention centres, and other prevention and treatment establishments. 7 laboratories located in Donetsk, Zaporizhzhya, Kherson, Lugansk, Odesa, Simferopil and Kyiv conduct confirmation tests. All the laboratories affiliated to the state medical establishments and conducting HIV antibodies testing report the number of screenings and the number of confirmed positive cases on a regular basis (monthly, quarterly, and yearly). During the last 2 years, a considerable number of private laboratories for HIV testing have also been established. There are no official statistics on their number, neither has a reporting model been developed for them.

16 Source: same as above, p. 15. 16 The advantages of the existing surveillance system · The Law of Ukraine stipulates voluntary HIV examination. · Operational information on the results of sero-epidemiological monitoring over the HIV infection spread in Ukraine reflects the scope and results of testing various sub- populations for the presence of antibodies to HIV, yet does not contain personal data. · Operational information on officially recorded HIV/AIDS cases covers all HIV/AIDS cases in individuals registered at prevention health centres. The data in this form are personalised, yet treated as confidential. · The tested groups are coded. This enables the researcher to identify the most vulnerable groups requiring urgent prevention interventions. · The strategy allows national monitoring of epidemic trends and monitoring and assessment of prevention programmes. · Data obtained in different regions of Ukraine are comparable. · Data obtained through epidemiological surveillance provides a basis for planning strategies to mitigate the epidemic’s effects. · Data obtained through epidemiological surveillance contribute to educating the public about the HIV problem.

Along with these there are a number of disadvantages: · Epidemiological surveillance provides data that might not be representative. Thus, blood donors know they are subjects for testing. · There are very few data on the HIV prevalence amongst prisoners. · Miscoding complicates the data analysis and leads to distortion of statistical data: for example, a pregnant woman using intravenous drugs might be coded either as a pregnant woman or an IDU. · The registered number of HIV/AIDS cases does not reflect the real situation in the country. According to estimates, diagnosed and recorded cases account for only 10-15% of the total. In accordance with the Ukrainian legislation, only those HIV positive individuals who have undergone clinical examination can be registered officially and can be diagnosed on the basis of its results, identifying the likely source of infection. Individuals with detected antibodies to HIV who avoid contacts with medical workers are not recorded officially. · The Law of Ukraine on AIDS Prevention and Social Protection of Population stipulates the prevalence of voluntary HIV examination (except donors’ blood samples). This law was aimed to protect the human rights of HIV positive people, yet made the collation of data obtained prior to and after 1998 complicated. · The system of data recording needs much improvement. Thus the database on pregnant women contains the number of tests conducted, which is not necessarily equal to the number of women tested · The existing system fails to explain changes in the epidemic’s development and does not reflect the real HIV situation in risk groups, particularly: IDUs, female sex workers and MSMs. · Even the available data are not fully used. It therefore seems reasonable to break up the data on HIV among young people by type of settlement, economic zone, etc. The national data-base should provide space for analysing particular groups of cases. · Test kits are another problem. Oblasts satisfy their demands for test-systems at the expense of national and local budgets. Non-availability of test kits is the most important factor affecting the registered HIV prevalence rate in particular region. This makes governmental statistics unreliable. · There is no single state testing strategy. Decisions are being made at the oblast level, depending on the local financial situation.

17 The existing system of epidemiological surveillance thus fails to assess the epidemic scope and to assist in developing policies needed to implement prevention programmes.

Sentinel Surveillance

Experience already gained In 1988 the World Health Organisation proposed sentinel surveillance as a more efficient instrument for following trends in HIV epidemic dynamics. Sentinel surveillance implies systematic data collection on HIV prevalence amongst different groups of population in certain territories during a certain period of time. Sentinel surveillance’s instrument is serological HIV surveillance primarily in HIV high-risk groups. In Ukraine, the first sentinel surveys were conducted in Odessa City among IDUs and female sex workers in 1997 and in Poltava among IDUs in 1998. Such surveys are based on anonymous unlinked testing method, making it impossible to identify the participant. If, according to routine sero-monitoring, the HIV prevalence among IDUs remained stable throughout the last three years and did not exceed 10%, sentinel surveys showed that it varied from 17% to 64% depending on the region. Obviously, the system of routine sero-monitoring fails to identify the real situation with the epidemic in the risk groups. The Ukrainian AIDS Centre planned to conduct sentinel surveys among IDUs, FSWs and patients with STIs in 2001. In the future, such surveys are planned to be conducted every year. In case the HIV prevalence among patients with STIs appears to be higher than 5%, other groups of population (such as pregnant women) should be surveyed.

The advantages of the sentinel surveillance system · Sentinel surveillance appears to be the only method providing relatively reliable data on HIV spread in such groups as intravenous drug users, men who have sex with men, female sex workers, patients with STIs and prisoners. · Sentinel surveillance helps to identify trends in spreading HIV by geographical area. · Sentinel surveillance monitors the epidemic over a certain period of time. · Sentinel surveillance provides possibilities to trace the epidemic trends within particular risk groups. · Sentinel surveillance provides data to assess intervention programmes in particular areas or targeted at particular groups.

The disadvantages of the sentinel surveillance system - Sentinel surveys are conducted at intervals. - They do not cover all oblasts. - They often lack a well-prepared staff.

Behavioural Monitoring

Experience already gained Behavioural surveys in the groups running a higher HIV infection or transmission risk than others, become an essential component in surveillance in a concentrated epidemic. The main objective of behavioural surveys is obtaining data on potential behavioural factors, conducive for HIV spread in society, factoring them into planning prevention activities as well as monitoring the prevention programme’s efficiency. Behavioural surveys in risk groups were initiated in Ukraine in 1996 and mostly dealt with researching specific counter-epidemic activities. Cconcurrently attempts were made to obtain data to enable the epidemic to be monitored over time. Such surveys have been and are being conducted mostly by various NGOs with financial support from international donors.

18 Advantages · Behavioural surveys are aimed at assessing and monitoring risk behaviours practised by particular risk groups which help to plan intervention programmes with maximum focus; · Behavioural surveys reveal links between population groups with low and higher risk of HIV infection. · When repeated, behavioural surveys help to identify behavioural changes related to HIV associated risks. · Behavioural surveys provide a basis for evaluating the efficiency of intervention programmes aimed at promoting behavioural changes in risk groups.

Problems currently faced · There is no a single framework of behavioural monitoring at the national level. · The NGOs often use different surveying methods, which makes findings non- comparable. · The reliability of the data is questionable as there is a lack of knowledge about the target groups, in particular their structure and number.

Based on the above it may be may concluded that the existing system of routine sero-monitoring that has been practised in Ukraine has failed to assess the HIV situation either in the vulnerable groups, or in the society as a whole. The available statistics as well as the data obtained from sentinel surveillance and behavioural surveys are definitely not enough to see precise figures. These data give a very general picture.

All this makes assessment and projecting the HIV/AIDS epidemic more difficult as the actual number of HIV infections in Ukraine is not known. Using the available data the opinion of experts’ of the Ukrainian AIDS Centre was taken into consideration for their reliability.

THE EPIDEMIOLOGICAL SITUATION IN UKRAINE

The data of routine epidemiological surveillance and sentinel surveillance provide some basis for understanding the general HIV situation in the country and show the HIV prevalence in particular groups. In 1995, the WHO included Ukraine among countries with low HIV prevalence. However, in that year the situation changed dramatically. HIV entered the IDU population and began to spread rapidly among young people. The number of monthly registered new infections varied from 700 to 1,000. The incidence reached its peak in 1997, when 8,934 cases were registered. Most of the infected people were male intravenous drug users. The dynamics of HIV registration is shown in Table 2.1.1.17 According to the sero-monitoring data, in 2000, the number of people tested increased by 64,512 (from 2,115,935 to 2,180,447), while, in 1999, the number of tests was 1.2 times lower than in 1998. At the same time, 1999-2000 were marked by a decrease in the number of tests, in particular among IDUs, which probably caused a decrease in the number of known HIV cases in 1999 (5,689). This decrease should by no means be regarded as a sign of stabilisation. The reason is general decrease in the number of tests for HIV, especially among IDUs. This was a result of adoption of the law On AIDS Prevention and Social Protection of the Population (March, 1998) that provided for voluntary testing

17 Information Bulletin «HIV in Ukraine» No. 19, Kyiv City, 2001

19 Table 2.1.1. Dynamics of HIV Registration in Ukraine from 1994 to 2001, persons (data provided by the Ukrainian AIDS Centre for 1987 –2001) Years Infected 1994 1995 1996 1997 1998 1999 2000 Total 2001 by group in 1987- 2000 Total number of 44 1,499 5,422 8,934 8,590 5,830 6,216 36,889 7,009 those HIV infected Ukrainian 31 1,490 5,400 8,913 8,575 5,827 6,212 36,600 7,000 nationals Including 0 12 99 210 402 549 737 2025 937 children Foreign 13 9 22 21 15 3 4 289 9 citizens

Table 2.1.2. Number of officially registered HIV infections (among Ukrainians) by region, persons (Source: Ukrainian AIDS Centre: Current statistics: the Problems of Drug Addiction, HIV and STIs in Ukraine. Information Bulletin 20020,. No.21.,) Region 1987-2000 2001 1987-2001 Crimea Republic 2,287 506 2,793 Vinnitsa 313 112 425 Volyn 348 62 410 Dniepropetrovsk 7,191 963 8,154 Donetsk 8,275 1,526 9,801 Zhytomyr 301 124 425 Zakarpati’ya 103 22 125 Zaporizhzhya 1,038 194 1,232 Ivano-frankivsk 96 20 116 Kyiv 324 228 552 Kirovograd 155 92 247 Lugansk 878 209 1,087 Lviv 307 120 427 Mykolaiv 2,580 412 2,992 Odesa 5,940 905 6,845 Poltava 852 138 990 Rivne 88 26 114 Sumy 181 77 258 Ternopil 169 40 209 Kharkiv 995 159 1,154 Kherson 518 131 649 Khmelnytsk 557 129 686 Cherkassy 870 184 1,054 Chernivtsi 257 22 279 Chernigiv 313 127 440 Kyiv City 1,186 345 1,531 Sevastopol City 478 127 605 TOTAL: 36,600 7,000 43,600

20 HIV Epidemic by Region The HIV situation in Ukraine is mixed. The epidemic is still being driven by intravenous drug use, therefore regions with high levels of IDU are the worst hit. The most affected regions are those in the east and south: Donetsk, Dnipropetrovsk, Odesa, Mykolaiv and the Crimea Autonomous Republic (see Table 2.1.2). They also have the highest level of intravenous drug use and HBV, an infection transmitted through the same modes as HIV. The highest prevalence rates are observed in the regions of Mykolaiv (among 39,856 tested in 2001, 977 appeared to have HIV), Odessa (134,305 tested, including 1200 with HIV) and Donetsk (192,292 tested, including 2301 with HIV). In Kyiv city, 128,689 people were tested and 1394 were reported HIV positive. According to serological HIV surveillance, in Ukraine 2,145,561 persons were tested in 2001. 12,743 were diagnosed as HIV positive (the prevalence rate thus was 0.59%).

Table 2.1.3. HIV infected by group in 1999-2000, persons Group 1999 2000 Tested Positive % Tested Positive % Ukrainians in total, including 2,109,642 9,796 0.46 2,175,153 11,965 0.55 Individuals who had sex with 4,530 377 8.32 4,640 423 9.12 HIV positive partners Children born to HIV positive 1,481 440 29.71 10,292 592 5.75 mothers * Intravenous drug users 45,955 3,956 8.61 47,122 4,534 9.62 Patients with STIs 131,318 826 0.63 114,843 817 0.71 Individuals partners 29,034 233 0.80 27,046 275 1.02 Blood donors and donors of 1,021,820 653 0.06 989,544 727 0.07 other biological liquids, organs, tissues Pregnant women 393,774 626 0.16 519,520 867 0.17 Prisoners 13,646 570 4.18 11,841 796 6.72 Examined according to clinical 149,710 1,124 0.75 147,272 1,613 1.10 indications Examined on voluntary basis 25,580 518 2.03 31,333 699 2.23 (anonymously or confidentially) Medical workers presumed to 7,536 8 0.11 5,154 16 0.31 have contacts with contaminated medical equipment Other 285,258 465 0.16 26,6546 606 0.23 Foreign nationals 6,293 7 0.11 5,294 21 0.40 Total tested 2,115,935 9,803 0.46 2,180,447 11,986 0.56

As table 2.1.3 demonstrates, the HIV rate hardly changed among blood donors (0.06- 0.07%) and pregnant women (0.16%-0.17%) in 1999-2000. In general the number of those diagnosed as HIV infected was larger in 2000 than in 1999 (0.56% against 0.46%). These include sexual partners of HIV infected persons (from 8.32% to 9.12%), IDUs (from 8.61% to 9.62%), convicts (from 4.20% to 6.72%) and those tested according to clinical indications (from 0.75% to 1.10%). *It is worth noting that though the registered number of HIV cases among children born to HIV positive mothers” decreased from 29.7 % (1999) to 5.7% (2000), the decrease in numbers can be explained by the fact that in 2000, the children tested also included some whose mothers’ HIV status was not known .

21 HIV prevalence by mode of transmission

Intravenous drug use remains responsible for most of the infections in Ukraine. Yet, according to the Ukrainian AIDS Centre, over the last three years, the number of heterosexual transmissions has increased .

The current trends in transmission modes are shown in chart 2.2.1 below:

Chart 2.1.1

Number of HIV infections in Ukraine from 1995 – 2001 by modes of transmission)

7500 7448 7000 6500 6516 6000 5500 5000 4500 4360 3881 3964 4000 3771 3500 3000 Number of people 2500 1885 2000 1021 1385 1323 1427 1500 1,007 709 914 1000 727 312 378 527 500 9 236 260 294 202 173 231 0 143 92 196 3 5 3 2 1 1 4 1995 1996 1997 1998 1999 2000 2001 Years Homosexual Heterosexual IDU From mother to child Unidentified

The order of importance of these has been changing throughout the epidemic. Over the last five years, the proportion of infections caused by intravenous drug use decreased from 83.6% (1997) to 56.5% (2001) of the total, while the percentage of heterosexually transmitted infections grew from 11.3% (1997) to 26.9% (2001). The statistics on mother to child transmission are alarming: 196 cases were diagnosed in 1997 (2.2% of all infected at that time) while in 2001, the numbers rose to 914 (13.1%) 18. Experts in the field believe the governmental statistics do not reflect the real situation. The estimated number of HIV infected in 2001 was between 330,000 – 410,000.

18 HIV/AIDS Surveillance in Ukraine (1987-2000), 2000, Kyiv City, p. 21-22.

22 HIV infection in various groups

In order to understand the situation in particular groups the following needs to be considered.

Donors Given the legally mandatory nature of HIV testing for each case of blood donation in Ukraine, blood-testing results cannot provide reliable data of infection prevalence in the general population. Most of the donors go through a kind of ‘self-selection’ knowing that they will definitely be HIV tested. Besides, access to blood donation services is a problem in some areas. Donor blood screening started in 1989 by order of the Health Minister of the USSR and is still in place today. The Centre for Donor Blood Infection Safety (Lviv Research Institute for Haematology and Transfusiology of the Academy of Medical Science of Ukraine) has responsibility for donor blood and blood components safety. In Ukraine, blood donation is paid for (except for close relatives of the recipient) and is therefore considered by some in the risk groups as a source of additional income. Consequently, between 1997 and 2000, 1,800 HIV infected donors were detected in Ukraine. Most of these were intravenous drug users. Between 1998-2000, the proportion of HIV infected in this group increased from 0.066% to 0.073%. The highest numbers of HIV positive donors were identified in the regions of Dniepropetrivsk, Odesa, Kyiv, Mykolaiv, and the Crimean Autonomous Republic

Pregnant women Between 1987 and 1993, all pregnant women were subjected to mandatory testing: those who were first registered and hospitalised for delivery had to undergo it twice, those who terminated the pregnancy once. In 1994, lack of funding created limitations on centralised test kits supplies. This reduced the number of pregnant women who underwent HIV tests. In 1998, the new law of voluntary HIV testing (with the exception of blood donors) caused a sharp decline in the number of tests in many regions and essentially complicated surveillance among this group. Another ambiguous issue is that the records provide for the number of tests, not the number of individuals tested. The data therefore are not always accurate as a patient of an antenatal clinic might be tested twice. More recently, the number of tests among pregnant women has increased substantially as part of an HIV prevalence strategy. This provides more data to assess the prevalence rate among the general sexually active population (Table 2.1.5). According to the Ukrainian AIDS Centre, the number of HIV cases among pregnant women increased during the last four years (1998-2001) from 0.120% to O.22%. During the period 1998 – 2001, the number of infections among pregnant women grew steadily. The highest numbers of HIV positive pregnant women were registered in Dnipropetrovsk and Odessa Regions. These are regions with traditionally high levels of intravenous drug use. Lower figures in other regions might mean that fewer tests are being carried out. The reasons are lack of test kits or even non-availability of counselling services that would inform women of the opportunity to have a test. However, since most of Ukrainian pregnant women report to antenatal clinics, the data (if accurate, of course) can be regarded as representative in terms of HIV prevalence rate among the general sexually active population. Since 2000, a considerable amount of work is being done in order to prevent vertical transmission. The prevention strategy seeks to reach the widest possible coverage of pregnant women with their consent.

23 Mother to child transmission Mother to child (vertical) transmission is an important cause of HIV infection. It is known that a child can be infected with HIV at the pre-natal stage, at the time of delivery or post-natally. Currently, the risk of mother to child transmission is about 30%. The Ukrainian AIDS Centre predicts it to decrease to 7% in 2002 and 5% or less in 2003-2010 on conditions that medical prevention of vertical transmission is properly introduced. In 2000, 727 children were registered with HIV anti-bodies.

Table 2.1.4. HIV infection among newly born (mother to child transmission), persons (data provided by the Ukrainian AIDS Centre) 1998 1999 2000 Boys Girls Total Boys Girls Total Boys Girls Total 199 179 378 147 144 291 358 369 727

Intravenous drug users The HIV epidemic amongst IDUs in Ukraine exploded earlier than in other CIS states. Today, one may witness the consequences: the number of IDUs developing AIDS grows rapidly. Unsafe practices of drug production and use caused the first cases. While the situation is more or less stable in the areas where the epidemic originated, those affected later have the highest prevalence. According to the Health Ministry of Ukraine, by 1 January, 2001, 75,489 persons were officially recorded as drug addicts . The existing recording system does not provide data specifically on injecting users, i.e. there are no governmental statistics on IDUs. However, the estimated percentage of IDUs among all drug users is roughly 80%, yet it might vary significantly by region. The number of HIV infected IDUs also vary by region. Throughout 1999 and 2000, sentinel surveys among IDUs were conducted in 6 big cities in Ukraine. These surveys were based on anonymous unlinked testing methods. Residual blood in IDUs’ syringes was used as samples. The results are shown in table 2.1.10.

24 Table 2.1.5. HIV among pregnant women by region, persons (data provided by the Ukrainian AIDS Centre: current statistics) Region 1998 1999 2000 Tested Positive % Tested Positive % Tested Positive % Crimea Republic 64, 628 47 0.073 38,237 35 0.092 40,114 71 0.177 Vinnitsa 6, 402 1 0.016 2,379 2 0.084 11,047 4 0.036 Volyn 96 0 0.000 1,209 3 0.248 1,961 2 0.102 Dniepropetrovsk 50, 690 104 0,205 44, 361 87 0.196 45,392 99 0.218 Donetsk 57, 846 134 0.232 53,244 161 0.302 55,238 187 0.339 Zhytomyr 11, 835 3 0.025 12,098 11 0.091 10,412 8 0.077 Zakarpati’ya 23, 681 1 0.004 19,250 3 0.016 12, 657 0 0.000 Zaporizhzhya 7, 028 7 0.100 3,766 4 0.106 13,247 14 0.106 Ivano-frankivsk 23, 358 4 0.017 13,923 2 0.014 6,752 3 0.044 Kyiv 6, 153 16 0.260 9,638 25 0.259 17,975 44 0.245 Kirovograd 8, 690 4 0.046 738 1 0.136 2,902 4 0.138 Lugansk 9, 183 6 0.065 10,612 1 0.009 24,009 12 0.050 Lviv 22, 629 2 0.009 3,798 0 0.000 32,857 15 0.046 Mykolaiv 5, 636 15 0.266 4,916 32 0.651 10,282 81 0.788 Odesa 56, 241 167 0.297 49,321 147 0.298 47,754 165 0.346 Poltava 44, 930 14 0,031 41,019 27 0.066 33,158 11 0.033 Rivne 64 0 0.000 718 0 0.000 7,816 1 0.013 Sumy 16, 266 3 0.018 11,585 3 0.026 11,616 2 0.017 Ternopil 0 0 - 1,431 0 0.000 6,208 1 0.016 Kharkiv 11, 898 1 0.008 16,248 6 0.037 27,23 15 0.054 Kherson 13, 491 7 0.052 17,798 16 0.090 23,741 23 0.097 Khmelnytsk 621 2 0.322 9,343 1 0.011 17,381 3 0.017 Cherkassy 651 1 0.154 526 2 0.380 10,284 19 0,185 Chernivtsi 8, 950 2 0.022 3,108 1 0.032 5,672 3 0.053 Chernigiv 2 0 0.000 19 4 21.053 3,236 9 0.278 Kyiv City 2,707 4 0.148 15,120 45 0.298 32,967 66 0.200 Sevastopol City 9,564 10 0.105 9,369 7 0.075 7,319 5 0.068 TOTAL: 463,240 555 0.120 393,774 626 0.159 519,520 867 0.167

25 Table 2.1.6.

Sentinel surveys among IDU19 City Persons surveyed (year) Prevalence, % Poltava 259 (1999) 37.8 259 (2000) 41.7 Donetsk 252 (2000 ) 39.7 Kryvyi Rig 249 (2000 ) 28.1 Odesa 293 (2000 ) 64.0 Simferopil 261 (2000 ) 27.2 Kharkiv 250 (2000.) 17.8

It is noteworthy that the sentinel surveys showed that the prevalence rate among male IDUs was normally lower than than among female IDUs (Poltava –99 by 15.4%, Poltava – 2000 by 6.4%, Donetsk by 16.8%, Simferopil by 6.5%, Odesa by 2.4%, Kharkiv by 8.0%). Male IDUs are more likely to have non-IDU sexual partners than female ones. A percentage of female IDUs provide sexual services for a drug dose or for money to purchase it. Therefore, female IDUs appear to be more vulnerable to HIV because they run a double risk – through sex and through drug use. Between May – July 2001, linked testing of 100 IDUs was conducted in Kharkiv under a WHO initiated research of intravenous drug use. (The WHO Survey of Intravenous Drug Users in Kharkiv City, 2nd Phase. The Project is being carried out by the UISR. 300 IDUs were to be tested by the end of 2001). 19% blood samples showed antibodies to HIV The blood testing was accompanied by a behavioural survey which allowed interpretation of the test results in a context of drug use and sexual practices.

Patients with STIs

Today, more focus is being given to the links between HIV and STIs. Besides being a serious threat to people's health, STIs significantly increase the risk of HIV. The possibility of acquiring HIV or infecting a sexual partner is 5-10 times higher for those suffering from an STI. The last twenty years have been marked by a sharp increase in STIs and skin diseases. The incidence rates for syphilis and gonorrhoea may serve as indicators of the general situation with STIs). In 2000, 45,245 Ukrainians contracted syphilis for the first time. Statistics show that the number of patients with syphilis has decreased since 1998, yet it remains at a high level. According to the Ukrainian AIDS Centre, 1998-2000 saw an increase in HIV rate among persons with STIs. In 1998, 0.525% of the 206,331 tested appeared to have HIV. In 1999, 0.629% of the 131,318 tested had HIV. In 2000, 0.711% of the 114,843 tested were HIV positive. The highest rates were seen in the southern regions of Mykolaiv (3.889%), Odesa (1.495%), Dniepropetrovsk (1.079%), Kyiv (0.994%) and Kyiv City (0.903%). In 2000, sentinel surveys for HIV among STI patients were conducted in 5 big cities in Ukraine. These surveys were based on anonymous unlinked testing method20. The surveys were conducted among the patients of the local venereal clinics in the cities of Kyiv (1.8% of the 500 tested were infected), Donetsk (1.3% of the 476 tested were infected), Mariupol in Donetsk Region (3.4% of the 386 tested), Gorlovka (0.3% of the 399 tested), and Slov’yansk in Donetsk Region 1.6% of the 447 tested).

19 HIV / AIDS Surveillance in Ukraine (1987-2000 ) 2000, Kyiv City, p..30. 20 HIV/AIDS Surveillance in Ukraine (1987-2000), 2000, Kyiv City, p. 32-33.

26 Persons with multiple sexual partners

Government statistics21 show an increase in the number of HIV infections among ‘promiscuous’ persons in 2000. In 1999, 233 representatives of this group were diagnosed with HIV (0.80%), and 275 in 2000 (1.02%). This indicates an increase in heterosexual transmission, which should be taken into consideration while planning intervention programmes. A special focus should be put on women, who provide paid sexual services as they have a large number of partners, as well as on men buying sex (clients of sex workers). According to the data obtained from a sociological study conducted by the UISR in 199722, 10% of young people in the age group of 15-28 years had 3 to 5 sexual partners in the year previous to the study, of whom 3% in the age group 21-24 years had over 10 partners. The data obtained from a national survey (3,250 young people were interviewed in October 1999) shows the following: § Most young people start sexual life between 16-18 years of age. § Over a quarter of those interviewed with sexual experience changed six or more partners in their lifetime. 43% had sex with more than one partner (from 2 to 5). 29% of the interviewed with sexual experience had one partner. § Those who had two or more partners during the previous three months face the highest HIV risk. They constitute 21% of the Ukrainian youth.

The current sexual behaviours create favourable conditions for the spread of HIV among heterosexual population.

Female sex workers (FSWs) Heterosexual transmission is on the rise. "Throughout the recent years, sexually transmitted infections have became widely spread in the countries of the former Soviet bloc. This suggests a considerable number of people practising unsafe sex with promiscuous partners’23. Many females using intravenous drugs are involved in commercial sex to obtain drugs or earn money for drugs. Many IDUs use the drug ephedrine. This drug stimulates sexual activity and may be regarded as one of the factors of HIV spread from the IDU group to a wider population24. Epidemiological surveillance of FSWs is extremely difficult. This is a very closed and hidden group. This is the reason why no data on HIV prevalence amongst FSWs are available. Sentinel surveillance seems to be the only method applicable for collecting data on this group. It is difficult to estimate the number of women involved in the sex industry in Ukraine. According to a sociological survey conducted in 1999-2000 by the UISR jointly with NGOs in the field of support to FSWs within the Project ‘Establishment of a NGO Network to Support Female Sex Workers’, the estimated number of FSWs in Ukraine is about 50,00025. This project covered 636 FSWs in 12 big cities of Ukraine26. From the data obtained, one FSW normally provides services to about 8 clients a week. In general, the number of clients per FSW varies from 1-3 to over 16 a week, which puts at risk the general population.

21 Kyiv Research Institute for Epidemiology of Infectious Diseases «HIV Infection in Ukraine», 1999, Kyiv City, p. 14. 22 The sociological study «Youth of Ukraine: values and cultural demands» was conducted by the Ukrainian Institute of Social Research in November – December 1997. The study targeted young people 15-28 years of age. The sample represented the Ukrainian youth by major socio-demographic characteristics and covered 1,496 respondents. 23 AIDS, epidemic update: December 1999// UNAIDS-WHO.- P.9. 24 AIDS: People and Countries / UN Project «STD and HIV/AIDS Prevention in Kirghis Republic», Kirland, 1999 25 Estimated by the UISR based on data provided by NGO operating in the field of support to FSWs and data obtained from the Institute’s research. 26 For more information on the Project see: «NGOs in HIV/AIDS Prevention among Female Sex Workers. The Outcomes of the Project «Establishment of a NGO Network to Support Female Sex Workers» , 2000, ?yiv City, Ukrainian Institute for Social Research, 2000, p.176.

27 In 1998 a sentinel survey was conducted in Odesa City in order to detect HIV prevalence among FSWs. 2.5% of the 241 women covered by the survey appeared to be HIV positive27. In 1999, a sentinel survey among 53 women providing sex services on the motorways of Donetsk City was conducted. The data showed a 13.2% HIV prevalence in this group. 37.7% of the surveyed were syphilis infected, 32% had HVC, 18.9% - HVC and syphilis, 9.4% - HIV, syphilis and HVC. One may argue on reliability of these data, yet they certainly show FSWs as a bridge through which the infection spreads to the general population.

Patients with TB 650,000 persons are currently officially registered in Ukraine as having tuberculosis, including 130,000 in its active form. According to the experts from the Yanovskiy Institute of Lung Diseases at the Academy of Medical Science of Ukraine, total testing would reveal 1.3-1.6 million cases. In 1999, 10,000 people died from tuberculosis. There are no government statistics on HIV cases among TB patients. The sentinel survey28 of this group conducted in Kyiv City revealed HIV antibodies in five samples (4 taken from men and 1 from a woman). The survey relied on anonymous unlinked testing. 352 blood serum samples were tested, including 247 male samples and 105 female samples in Kyiv. The infection rate reached 1.41%. Most of the tested were people 40 years and older. The data obtained from a sentinel survey among 625 prisoners with TB in various penitentiary institutions, including penitentiary hospitals showed the HIV prevalence rate from 8.1% (Poltava Region) to 12.0% (Dniepropetrovsk and Kherson Regions). High numbers of TB patients with HIV explains higher level of mortality from tuberculosis in the Ukrainian penitentiary system.

Prisoners 29 The current trends in HIV spread in the Ukraine’s penal system do not differ much from one state to another and reflect the general epidemiological situation in the country. Until 1996, prisoners were subjected to mandatory testing. Since 1998, according to the Ukrainian legislation, imprisoned persons have the right to voluntary HIV testing. Between 1987-1994, 11 HIV infected prisoners were registered in the penitentiary system, while 455 in 1995, 2,946 in 1996, 2,770 in 1997 and 1,096 in 1998. Over 90% of all cases were detected among those imprisoned before trial. In April 1999, the total number of HIV infected prisoners reached 4,300. According to the government statistics, by January 1, 2001, the Ukrainian penitentiary system reported 1,845 HIV infected persons, including 35 with full-blown AIDS. The decrease in number of registered infections in the penitentiary institutions does not reflect the real situation. In 2000, 625 prisoners were tested in penalty enforcement institutions, including TB hospitals and 73 were diagnosed with HIV (11.7%). The greatest number of cases were identified in the oblasts of Mykolaiv (26.4%), Dniepropetrovsk and Poltava (4.3% and 4.8% respectively).A large number of HIV positive cases in Mykolaiv regions is accounted for by its inmates being mainly residents of this region, which has one of the highest HIV incidences in Ukraine30.

27 Source: «HIV/STD Prevention amongst Female Sex Workers in Odesa City» // A report provided by the NGO «Faith, Hope, Love», Odesa City, 1999, page 12. 28 «HIV/AIDS Surveillance in Ukraine» (1987-2000) ?yiv, 2000 p. 35. 29 O. Gunchenko «HIB in the Ukrainian Penitentiary System and Perspectives for Collaboration with NGOs,« HIV: a Variety of Aspects Digest, No. 7, Kyiv City, 2001, p.51-53.

30 Gunchenko «HIV in the Ukrainian Penitentiary System and Perspectives for Collaboration with NGOs,« HIV: a Variety of Aspects Digest, No. 7, Kyiv City, 2001, p.51-53.

28 Chart 2.1.2. Number of HIV positive convicts registered in Ukrainian penal institutions in 1987-2000

2939 Uniform 2732 3000 ed 2500 Services 31 2000

1500 This is 1042 another 1000 451 very 357 500 closed 11 group 0 1987-1994 1995 1996 1997 1998 1999 controll ed by the Defence Ministry and the Ministry of Internal Affairs. Data on health conditions of the Ukrainian military and the police staff are rarely available to the wider public. It is reported that approximately 300 HIV persons have been identified in the Armed Forces. In 2000, an anonymous unlinked testing of servicemen was conducted. Medical establishments providing health care services to Ministry of Internal Affairs staff in Kyiv City and Kyiv Oblast were selected as sentinel sites. Blood serum remaining from other laboratory tests was used. 2 out of 270 samples contained HIV antibodies (0.73%)

Men who have sex with men There is still a belief that HIV is a disease of the gay population. The data being collected by the Ukrainian AIDS Centre since 1987 show that homosexual transmission is not a major factor in the HIV transmission in Ukraine. In 2000, 4 HIV cases were identified among homosexual men: 2 among 20-29 year olds while 2 among those were 30-39 years old.

Other groups Theoretical assumptions and the experience of other countries show the need of a separate analysis of the so-called mobile groups. In Ukraine, these are traditionally truck drivers, train conductors and sailors. Transformation of the labour market and market transition resulted in emergence of occupations previously unknown: entrepreneurs trading in the CIS countries and overseas, those working in tourist business, etc. Women are widely represented in this group and at fairly high risk of sexual violence while travelling. They stay away from their steady sexual partners for a long time and therefore seek alternative partners. Migrants and seasonal workers are also in the mobile group. The role of the mobile groups in the epidemic spread should be studied in order to gain better understanding of the epidemic trends and to design efficient intervention programmes.

2.2. AIDS data In this section an attempt is made to describe the complicated situation with the registration of AIDS cases in Ukraine and to analyse the existing governmental statistics in the field and the prevailing public attitudes to people with HIV and AIDS.

31 HIV/AIDS Surveillance in Ukraine (1987-2000), Kyiv City, 2000, p.35.

29 AIDS epidemiological surveillance in Ukraine The HIV/AIDS surveillance system was put in place in Ukraine in 1987. The definition provided by the European Centre for AIDS Epidemiological Monitoring was relied upon for AIDS cases registration including obligatory diagnosing of one of the AIDS indicator diseases according to the list provided by the Centre32. Adequately coded data were submitted to the Centre on a quarterly basis for inclusion into the general European register of AIDS cases.

Data now obtained through sentinel surveillance contains statistics on all infections associated with AIDS.

The biggest problem with AIDS data is that very often the disease is diagnosed too late. According to the Ukrainian AIDS Centre, about 10% of the cases were diagnosed at late stages when the patient was actually dying. There is therefore a likelihood that many AIDS cases are not recorded. The limited AIDS statistics, especially in the context of much more informative HIV data, seriously constrains analysis of the AIDS situation and complicates prevention and treatment. One of the strategies for improving the situation regarding diagnostics of AIDS would be to increase the knowledge of the medical staff so that AIDS is speedily and correctly diagnosed and registered.

Table 2.2.1 Registration of AIDS cases in Ukraine, persons

Year 1987- 1995 1996 1997 1998 1999 2000 2001 Total 1994 Total number of people 37 45 146 193 399 586 648 869 2923 with AIDS, including : - Ukrainian nationals, 32 45 143 189 398 586 647 867 2907 Including children 6 1 10 4 14 15 13 30 93 - foreign citizens 5 0 3 4 1 0 1 2 16

An overview of the general situation in Ukraine The figures from the Ukrainian AIDS Centre show that in 2001 869 persons developed AIDS symptoms which is an increase of 221 cases from the previous year (648 cases). The existing statistics are able to provide an analysis of the situation in the context of gender, age and modes of transmission.

In 2000, 490 men were registered with AIDS. Most of these (407) were infected through intravenous drug use, while 68 cases were heterosexually transmitted. Other cases are of unknown transmission.

One can observe a similar picture amongst women. 105 of the 157 registered women with AIDS were infected through drug use. 36 acquired HIV through heterosexual intercourse, 9 were infected by their mothers. The age groups of 20-29 and 30-39 year olds are most affected among both men and women.

AIDS spread by region Between 1987 and 2001, the largest number of AIDS cases were registered in the oblasts of Odesa (1,188), Mykolaiv (353), Donetsk (349) and Crimea Autonomous Republic (327). In total 2,907cases were recorded in Ukraine for this period.(see: Appendix 3, table 5). Since AIDS is a fatal disease, it is possible to predict mortality rates based on the number of recorded cases.

32 HIV/AIDS Surveillance in Ukraine (1987-2000), 2000, Kyiv City, p.15-16.

30 AIDS mortality Between 1987 and 2001, 1,473 persons died from AIDS, including 47 children. In 2001, 473 AIDS deaths, including 2 children were registered. (see Table 2.2.2). Table 2.2.2. AIDS mortality in Ukraine, persons 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001, Total

Number of deaths (overall total), including 0 2 1 1 2 3 4 5 20 70 85 150 253 415 473 1, 485

Ukrainian nationals, including 0 2 1 1 2 3 4 2 19 69 82 148 253 414 473 1,473

Children 0 1 1 0 2 0 0 0 1 6 4 9 12 9 2 47

Foreign nationals 0 0 0 0 0 0 0 0 3 1 1 3 2 1 1 12

AIDS mortality by region is shown in Appendix 3, table 6. For the period 1987-2001, the largest number of AIDS related deaths were registered in Odesa oblast (625), Mykolaiv oblast (243), Donetsk (188) and Crimea (133) i.e. the areas with highest HIV prevalence.

31 2.3 General Conclusions.

The following conclusions can therefore be drawn: 1. The system of routine sero-monitoring that is currently being practised in Ukraine has failed to assess the HIV situation in both the susceptible groups and the society as a whole. In fact, sentinel and behavioural surveillance appeared to be the only method providing relatively reliable data on HIV spread in such groups as intravenous drug users, men who have sex with men, female sex workers, and prisoners. There needs to be a co-ordinated government led national programme of sentinel surveillance in order to collect and collate reliable data. 2. The existing system of HIV surveillance, testing, diagnostics and case registration is far from perfect. This affects the quality of data reporting and limits the possibilities of projecting the epidemic. 3. According to the Ukrainian AIDS Centre, between 1987 and 2001, 43,600 HIV infections were registered in Ukraine, including 2,962 infected children. 4. There is no uniform picture of the HIV situation in Ukraine. However the HIV rates seem to be reflected by the extent to which intravenous drug use is spread in each area. 5. The worst hit oblasts are Dnieproptrovsk, Donetsk, Odesa, Mykolaiv and the Autonomous Republic of Crimea. These are the oblasts with the highest levels of intravenous drug use and HBV, a disease that has the same modes of transmission as HIV. 6. Intravenous drug use remains the cause for most of the HIV cases, which might be explained by the steady increase in the number of IDUs. Yet, during the last three years, the number of heterosexual transmissions has risen, so too the numbers of mother to child transmissions. 7. Given the rapid spread of HIV, proper assessment and projection of the epidemic as well as efficient prevention programmes targeting the general population become extremely important. 8. A national electronic database on HIV/AIDS is urgently needed. Such a database should provide possibilities for monitoring each recorded case of AIDS, including such indicators of the average period from HIV infection to illness, and the average period from falling ill to death, both in general and by risk group. 9. In order to assess and project the HIV/AIDS epidemic effectively, the existing system of case registration needs improvement at both the local and national levels. In particular, it should provide data on the numbers of AIDS deaths, and the proportion of patients with AIDS who died from reasons other than AIDS (eg overdose, suicide) , both by risk group and in general.

32 SECTION 3. METHODOLOGICAL APPROACHES

3.1. Concepts of susceptibility and vulnerability

The spread of the HIV/AIDS epidemic and the increase in numbers of newly registered cases require development and implementation of a set of prevention and care interventions. These are based on two important concepts - susceptibility and vulnerability - that have been developed as a result of research work in Europe, India and Africa by Tony Barnett (School of Development Studies, University of East Anglia, Norwich) and Alan Whiteside (Health Economic and AIDS Research Division HEARD, University of Natal, Durban). At the moment, these concepts are not being used widely in Ukraine as in the Ukrainian language, the terms “vulnerability” and susceptibility” might mean the same. Often vulnerable groups are described as susceptible and vice versa.

Susceptibility refers to the individual group, and general social predisposition to infection. This concept may be applied at any level, from an entire society or country to a household. Thus, individuals, nations, and societies are more or less susceptible to infection, and the speed and extend of the spread of HIV will be determined by the susceptibility. Considering the social and economic impacts of HIV, the concept of susceptibility is especially important as it can be applied to at the level of social and / or economic units: organisations, services, companies, etc. Susceptibility shows the extent to which social, economic, cultural and ecological conditions increase the disease prevalence. The epidemic’s development is a curve with the highest point representing the highest prevalence rate.

The factors characterising the susceptibility of the Ukrainian society might be divided into the following main groups: - infrastructural (eg, the infrastructures of rural and urban areas differ substantially) - environmental (eg, the environmental situation in the east regions of Ukraine causes migration to other parts of the country) - cultural (acceptance especially in recent years, of various patterns of sexual behaviour; religions, etc.) - economic (income gaps, unemployment, shadow economy) - social (general decline of the youth leisure services, poor standards of medical system)

Vulnerability refers to those features of social and economic entity that make it more or less likely that the excess morbidity and mortality associated with diseases will have adverse impact upon that entity33. Thus, families, communities, and societies will be more or less vulnerable to the impact of increased morbidity and mortality.

The distinction is made between the two terms because a society may be susceptible but not vulnerable. However, a good example of both susceptibility and vulnerability is female sex workers who are the only bread winners in their families, and often single mothers

The HIV epidemic does not develop in a vacuum, it has a social context. An attempt is made below to analyse the situation in which the HIV/AIDS epidemic spreads, to characterise the factors contributing to the epidemic and to demonstrate the inter-relations between the socio-economic situation and the HIV prevalence in the country. As earlier stated, HIV is a virus a person can contract often as a result of his/her behaviour. However, this largely depends on the individual’s environment, living conditions, social norms and personal habits. What influences behaviour and finally form the epidemic’s trends in the Ukrainian society? Chart 3.1.1. shows the determinants of HIV epidemic.

33 See: Social and Economic Impact of HIV / AIDS in Ukraine Kyiv, 1997, page 4.

33 Table 3.1.1 Factors affecting HIV/AIDDS epidemic

MACROFACTORS SOCIAL AND BEHAVIOURAL BIOMEDICAL ECONOMIC ENVIRONMENT Economic crisis - Urbanisation Sexual behaviours (rate Virus subtypes - Mobility of partner change, Welfare - Migration number of partners, Stage of infection -Availability of unsafe sex, sexual State polices medical services practises) Presence of STIs - Crime rate Culture - Violence rate Practises of intravenous - Infrastructure of drug use (sharing Gender Religion leisure facilities needles/syringes, use of - Poverty contaminated syringes, Income distribution - Unemployment sharing vessels, use of - Level of social blood as a cleansing tension agent, etc.) Social cohesion in the - Situation with civil society rights and men –Rituals involving blood women equality Education - Level of drug use Personal hygiene - Public attitudes to (sharing razors and other Practised HIV/AIDS issues toiletries) governmental policies

Economic crisis

3.2. Description of Models of the Development of HIV/AIDS epidemic Ukraine and incoming data These projections are not intended to be forecasts of what will happen, rather they should be considered as possible scenarios of the epidemic’s development. The projections presented may enable experts in the field and politicians to analyse and understand possible impacts and plan for interventions in order to mitigate the possible HIV/AIDS impacts. In order to project the development of the HIV/AIDS epidemic in Ukraine the Spectrum programme (“Spectrum Policy Modelling System”) developed by professionals of The Future Group International was used. The integrated package includes several components of which two were used: 1) Demography (Dem Proj), a programme for projecting demographic trends based on number of population, and fertility, mortality and migration; 2) AIDS (AIDS Impact Model) – a programme aimed at projecting AIDS impacts. While comments on the input data are made here, the major results are presented in sections 5 and 6 of this report. 1994 was taken as the start of the epidemic. The projection covers the period until 2010 i.e. nine years ahead. It was unanimously decided that the available statistical data, in particular in the field of HIV, are not sufficiently reliable for building a longer-term projection.

34 In fact, the input data on the demographic situation demonstrates how the situation would develop without AIDS.

I. The demographic characteristics of Ukraine used for projecting the number and gender-age structure of the population in 1994-2001

1. The Ukrainian population by gender and age in the beginning of 1994

2. Fertility The projection assumed that a sharp decrease in fertility in the 90s would be followed by some stabilisation in another five years, after which some increase is expected. In particular, the total fertility rate in 2001-2005 is expected to be 1.10-1.13 children per woman and to rise to 1.23 in 2005-2010. Moreover, the input from the youngest age group of mothers decreases, while the proportion of women with children among those over 25-30 will somewhat grow

3. Mortality The projection envisages a slow and gradual decrease in mortality in Ukraine. Based on the current socio-demographic situation in Ukraine and considering the first signs of stabilisation, it is assumed that in the next 10 years there would be factors preventing further deterioration of the health condition of the Ukrainian population, which, in turn, would lead to some decrease in mortality and increase in life expectancy. This assumption matches the professional opinion of demographers34. Besides, the preliminary data available show some decrease in mortality in 2001. According to the hypothesis by the end of the term of projection the average life expectancy would be at the level of the early 90s (i.e. the pre-crisis rate).

5. External migration The existing hypothesises examining trends in migration are based on extremely contradictory and sometimes unproven suppositions. This projection assumed a gradual decrease of the migration negative balance from (- 40 thousand) in 2005 to (-30 thousand) in 2010. The migration activity is predicted to be higher among men. Considering the age structure of potential migrants, the annual data from 1994-2000 was used to predict the future trends.

??. AIDS Impact

1. The estimated HIV prevalence among the adult population in 1994, i.e when the epidemic began, and perspectives for further spread. According to the WHO and UNAIDS, in the current year, the HIV prevalence among the Ukrainian adult population has reached 1%, which is considerably higher than the officially registered figure. At the beginning of the epidemic, the prevalence rate was close to 0%. The programme “Epimodel” was used in order to develop a possible scenario of the epidemic. Two scenarios were developed in the model. According to the optimistic scenario, the HIV prevalence will not exceed 2% by 2010. According to the pessimistic scenario, the Ukrainian epidemic will enter the generalised stage with the prevalence rate among adults 5% or more.

2. Mother to child transition. In 1999, 30% of all HIV positive mothers infected their children, while 25% in 2000. According to the Ukrainian AIDS Centre, the introduction of drug treatment might decrease the possibility of infection to 10% in 2001, 7% in 2002 and 5% in 2003-2010.

34 V. Steshenko, O. Rudnytskiy, O. Khomra, A. Stefanovskiy, Demographic Perspectives of Ukraine by 2026, Kyiv, The Institute of Economics at the National Academy of Science of Ukraine, 1999 p. 56.

35 3.Percentage of HIV positive children that die in the first year of life was estimated on the basis of data provided by the State AIDS Prevention Centre. However these are far from complete and therefore not statistically representative The rough estimate used in the projection was 20% (suggested by Y. Kruglov).

4. Average expectancy of life with AIDS. According to numerous studies in different countries it might last from 6 to 18 months. Since there are no reliable statistics on the matter, one year was taken as a very rough average.

5. Percentage decrease in fertility among HIV positive women. The professional opinion of Dr. Kruglov suggested that it might be 75%.

6. HIV incubation period, i.e. the period from HIV infection to illness. The programme offered slow, average or fast model. The analysis of the current epidemiological situation gave grounds to use the average model.

7. Distribution of new cases by age groups for men and women. The available HIV statistics are insufficient to determine the situation amongst 25-29 year olds as required by the programme. Thus rough indicators were used as offered by the model.

8. Ratio of female to male prevalence. For 1994-2000, the figures were based on the available statistics: in 1994 it was male to female – 1:0.35 and in 2000 it was 1:057 It was assumed that in the context of the increase in the number of heterosexual transmissions, the ratio would reach 1:1 by 2010.

9. Data to identify impacts on the health care system. The government statistics were used when available otherwise the data was based on estimates.

36 3.3. Projecting the HIV/AIDS Epidemic in Ukraine: main results

As stated in Section 2, the exact number of HIV infected people in Ukraine is unknown. However, estimation techniques allow an assessment of the scale of the epidemic. This requires such indicators as the size of populations at higher risk (IDUs, FSWs, etc.) It is also necessary to know the scale of the HIV epidemic in particular groups. For the rest of the population, the situation amongst pregnant women might conventionally serve as an indicator. The calculations within the EPIMODEL demonstrated that HIV positive people constitute about 1% of the adult population in Ukraine. Various assumptions suggest 330-410,000. Based on these figures, two scenarios, optimistic and pessimistic, were modelled in order to assess the potential epidemic’s impacts, losses it will cause and the related costs. The tables and charts below present the major results of the projection by two scenarios35. Table 3.3.1.

Projected number of HIV infections (millions of persons) and prevalence among the adult population (%)

Optimistic scenario Pessimistic scenario Year Number of HIV HIV prevalence Number of HIV infected HIV prevalence infected Total Men Wom Total Men Wom (mln.) en (mln.) en 2002 0.37 0.22 0.15 1.18 0.53 0.32 0.21 1.73 2003 0.40 0.23 0.17 1.28 0.66 0,38 0.27 2.12 2004 0.43 0.25 0.18 1.38 0.78 0.45 0.33 2.52 2005 0.46 0.25 0.20 1.47 0.90 0.50 0.40 2.92 2006 0.48 0.26 0.22 1.57 1.02 0.55 0.46 3.32 2007 0.51 0.27 0.24 1.67 1.13 0.60 0.53 3.72 2008 0.54 0.28 0.26 1.77 1.24 0.65 0.59 4.12 2009 0.56 0.28 0.28 1.87 1.35 0.68 0.66 4.52 2010 0.58 0.29 0.29 1.97 1.44 0.72 0.72 4.91

Table 3.3.2. New AIDS cases and number of deaths caused by AIDS (thousands of persons) Optimistic scenario Pessimistic scenario New AIDS Died in a year New AIDS Died in a year Year cases number per thousand cases number per thousand 2002 17.86 15.51 0.32 17.86 15.51 0.32 2003 22.49 20.17 0.42 24.73 21.30 0.44 2004 27.85 25.17 0.53 32.00 28.36 0.60 2005 31.69 29.77 0.63 40.61 36.31 0.77 2006 35.14 33.42 0.72 50.11 45.36 0.97 2007 37.84 36.49 0.79 61.26 55.69 1.20 2008 40.09 38.97 0.85 71.78 66.52 1.45 2009 42.43 41.26 0.91 83.19 77.48 1.71 2010 44.36 43.40 0.96 95.21 89.20 1.99

35 Full tables for the both scenarios are given in the Appendix 2

37 Chart 3.3.1. Number of HIV infections according to the optimistic and pessimistic scenarios of the HIV/AIDS development in Ukraine

Chart 3.3.2. Number of new AIDS cases according to the optimistic and pessimistic scenarios

38 Chart 3.3.3. Cumulative total of AIDS related deaths according to the pessimistic and optimistic scenario

According to the optimistic scenario, the number of HIV positive people will exceed half a million by 2010 (582000), the number of new cases will reach 44,360, while the number of deaths – 43,400. The situation will require more investment in the response to the epidemic, there will be a greater need of hospital beds, the attendance of medical establishments will increase, etc. (see Appendix 2).

According to the pessimistic scenario, the number of HIV cases will reach 1.44 million by 2010, the number of new cases will be twice as high as the one assumed by the optimistic scenario (95,210 people), while the disease will kill 89,200 people.

Considering the prevention of the mother to child transmission, both scenarios are quite optimistic about the situation among the newly born, although the pessimistic scenario gives 2.5 times higher number of infections in this group: 273 against 110. The same tendencies will be observed with regard to children’s AIDS mortality (Chart 3.3.4). The number of children who will lose their parents is expected to be 463,700 by 2010 according to the optimistic scenario, while 773,600, according to the pessimistic one. The demographic and socio-economic impacts are analysed in details in the next sections.

39 Chart 3.3.4. Children’s AIDS mortality according to the optimistic and pessimistic scenarios

Chart 3.3.5. Projected number of children made orphans by the AIDS epidemic, according to the optimistic and pessimistic scenarios

40 SECTION 4. UKRAINE AS RISK ENVIRONMENT

4.1 Demographic Situation in Ukraine This section provides a brief review of the demographic situation in Ukraine, against the background of which the HIV/AIDS epidemics is developing in the country. The section uses official statistical data of the State Statistics Committee of Ukraine and the estimates of the Department of Demography and Renewal of Labour Resources of the Institute of Economy of the National Academy of Science of Ukraine.

Population Size, Age and Gender Structure In the beginning of 2001 the population in Ukraine was 49.29 million, including 33.54 million living in urban areas and 15.75 million in rural areas. The peak population rate was registered in the beginning of 1993 at 52.24 million. So between 1993 and 2000, the general population in Ukraine decreased by 2.95 million people. Ukraine has a disproportionately high level of the aged population which also affects the gender structure. In early 2001, the number of people in the age range of 69 years and older amounted to 20.8% of the population. The mean age of the population is 38.3 years which breaks down into 37.6 years in the cities and 39.8 years in the rural areas. The demographic effect on the population of productive age by people with disabilities is also significant, especially in the rural areas. At the start of 2000, the dependency ratio in the rural areas was 1,000 productive people to 994 disabled ones (416 children and 578 persons over the productive age). In the cities the demographic load on the productive population was 652 people (310 children and 342 persons over the able- bodied age). Due the abrupt decline in fertility in the 90’s, the age and gender pyramid of the Ukrainian population experienced significant changes and its foundation seriously narrowed (Fig. 4.1.1). Narrowing of the age pyramid results in the reduction of prerequisites for the favourable demographic prospects of Ukraine, which is associated with the depopulation, its irregular dynamics in the future, and decline not only in reproduction, but in the labour potential as well36.

Fertility The total number of births in Ukraine declined from 691,000 in 1989 to 385,000 in 2000. In urban areas this decline was almost 50% of the total, while in the rural areas 33%. During this period the general fertility rate decreased from 13.3 to 7.8 per 1,000 persons; in the cities, from 13.6 to 7.1 and in rural areas, from 12.9 to 9.3 respectively (Fig. 4.1.2). Compared to the pre-crisis period, fertility declined in all age groups both in urban and rural areas. In contrast to developed Western European countries, age-specific fertility in Ukraine has its own characteristics. In the 90’s the fertility rates in both urban and rural areas dropped below the level needed for the simple replacement of parents by children (Fig. 4.1.4). The cumulative fertility rate was very low: it declined from 1.9 children in 1989 to 1.1 in 2000. In the cities it decreased from 1.8 to 0.9, and in rural areas from 2.4 to 1.5. At the same time, the first signs of stabilization were observed in 1999 – 2000.

36 V. Steshenko, O. Rudnitsky, O Khomra , A. Stefanovsky. Demographic projections of Ukraine till 2026. – K.: Institute of Economy of NAS of Ukraine. – p. 16.

41 Chart 4.1.1 Population Sex and Age Structure in Ukraine in the Beginning of 2001

100+

Age Females 90 Males

80

70

60

50

40

30

20

10

0

2000 1500 1000 500 0 500 1000 1500 2000 thousands persons

Regional analysis shows that the birth rate is declining in the South-Eastern oblasts, while the highest growth is currently seen in the Western region of Ukraine37. The reasons for this regional diversity are different. It is influenced by purely structural factors (difference in the age structure of the population), as well as by social and economic factors.

37 In this case, basing on the division into demographic regions, the Western region of Ukraine include Volyn, Zakarpttia, Ivano- Frankivsk, Lviv, Rivne, Ternopil and Chernivtsi oblasts; Central region includes Vinnitsia, Zhitomyr, Kirovograd, Kyiv, Khmelnitsky and Cherkassy oblasts; North-Eastern region includes Poltava, Sumy and Chernihiv oblasts; Southern region – AR Crimea, Mykolayiv, Odessa and Kherson oblasts; South-Eastern region -- Dnipropetrovsk, Donetsk, Zaporizhja, Lugansk and Kharkiv oblasts.

42 Chart 4.1.2 Dynamics of General Fertility, Mortality and Natural Growth (Decline) Rate of the Population in 1989 – 2000 (per 1,000 persons)

20

15

10 General fertility rate

General mortality rate 5 General rate of natural growth (decline)

0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

-5

-10

Chart 4.1.3. Dynamics of the Accumulated Fertility Index in Ukraine in 1989 – 2000*

2.5

2

Urban settlements

1.5 Rrural areas

Urban settlements and 1 rural areas

0.5

0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 * average number of children that a woman can bear under the condition that she will live through her child- bearing age, and that existing age-specific fertility rates will be preserved.

43 Health and Mortality

Excessive alcohol consumption is another powerful factor, increasing the risk of premature death. However, the alcohol factor is not the only and final explanation of the reasons of the abrupt growth of mortality and associated population loss in the 90’s. Increase of mortality in Ukraine is explained by a complex of long-term causes: drawbacks of the state health protection system formed in the Soviet times; current social and economic decline and related crisis of the health protection framework; decrease in the living standards; worsening of environmental conditions; lack of a proper assessment and understanding of the value of health by both the government and the population. According to a preliminary estimate, in 2000 the life expectancy was 62.2 years for men and 73.5 years for women. The increase in the mortality rate in the 90’s occurred in practically all age groups, including children in the first year of life. Mortality in the first year of life is the highest in the South and South-East; it is also high in the West and South-East of Ukraine. The situation in the Central regions is comparatively good. The low life expectancy in Ukraine is influenced by the mortality of adults in productive age, rather than by the mortality of children and pensioners. The impact of mortality among population aged 30 to 60 years is the most significant. This age provides the best opportunities to extend the life expectancy in Ukraine. Gender differences are most visibly seen in the age between 20 and 40 years, when the probability of death among men is by 3 – 3.5 times higher than that of women. Excessive mortality of men in Ukraine is not caused by purely biological factors; it is rather the consequence of unhealthy life-style, unfavourable working conditions, excessive consumption of alcohol and tobacco.

Consequently: · Due to the significant decrease in fertility and dramatic increase of mortality, Ukraine has been experiencing depopulation since 1991 (it started in the rural areas from 1979). If in 1991 the natural loss of population was 39,200 thousand people, then in 2000 it amounted to 373,000 people. During last 10 years Ukraine has lost 2.5 million people due to depopulation. It is visible all over Ukraine. In 2000 a small natural growth of the population was observed only in the rural areas of Zakarpattia region.

· Demographic projections of Ukraine are closely related to its social and economic prospects. No significant improvements in the economic and social situation have occurred as yet, and the existing social and economic uncertainty determines the unclear demographic trends in the future. If changes in fertility are probably irreversible, then there are still possibilities to improve the situation with mortality. At the same time, the spread of HIV/AIDS is a factor that narrows such opportunities and hampers the opportunities for Ukraine to have a way out of the demographic crisis.

· The current demographic situation will contribute to the nation’s HIV susceptibility and (especially) vulnerability. Ukrainian society is already extremely “exhausted” demographically, which, in turn, unfolds the impacts of the HIV/AIDS epidemic. Among the many effects of the epidemic, demographic effects are certainly very important. Section 5.1 attempts to foresee some demographic impacts the epidemic might have in Ukraine.

44 4.2 Social and economic characteristics of the contemporary Ukrainian society

The last decade in Ukraine as a sovereign state was marked with a crisis in practically all spheres. The HIV/AIDS epidemic in Ukraine occurred in the context of economic decline, falling production and increasing unemployment, income differential, increase in poverty, active migration and budget deficits.

Economic development

World history does not give an example of a crisis of this scale in peaceful times. The economic crisis not only aids the spread of the epidemic, it affects the society’s potential to deal with it. 1990-1994 was the worst time for the Ukrainian economy. During this period, the Gross Domestic Product dropped by 45.6%, industrial output by 40.4%, and agricultural output by 32.5%. In 1994 alone, the GDP decline reached 22.9%, industrial output fell by 27.3%, including 37.5%, in the non-agricultural and 16.5% in the agricultural sector. The financial sector was a complete mess. The state budget deficit was covered by direct financial interventions from the National Bank of Ukraine. In 1994 alone, the exchange rate of the Ukrainian currency (karbovanets) fell 8.3 times against US$. In 2000, the number of unemployed people was 2,707,000 (11.7% of the economically active population 15-70 years of age). Moreover, the majority of these (63.5%) stayed unemployed for over a year. 40% lost jobs due to administrative re-organization, closure of companies and plants, massive reductions in the war industry and staff reductions. Unemployment and increased poverty have caused expansion of shadow economies, including those associated with crime, sex work, trafficking and drug use. Regular or occasional sex work increasingly provides a means for economic survival for many people, mostly women. These are also major causes for the sharp increase in alcohol consumption. Evidence suggests increased rates of multiple sexual partners are associated with migration. Since 1991, drug markets have proliferated in the CIS countries, particularly in the domestically produced injecting opiates. In Ukraine, drug markets have become increasingly commercialised and monopolised. Most of the users are on cheap dirty drugs, the preparation of which requires blood as a cleaning agent. Recently, commercial drug dealers have begun to target smaller urban and rural areas as larger markets become saturated. In 2000, the Ukrainian economy demonstrated some changes for the better. The Gross Domestic Product increased by 6.0 %, industrial output by 12.9%, and agricultural productivity by 9.2%. Some positive shifts have been seen in the financial sector (e.g. increase in crediting, investment, and export potential, decrease in the foreign debt, and a general growth of the economy). The improvement was witnessed by growing labour productivity. According to the State Statistic Committee of Ukraine, in 1997, the productivity index (as compared with the previous year) was 107.1%, while 103.9% in 1998, 109.6% in 1999 and 115.3% in the first half of 2000. In 1999, the growth of industrial output by 4.0%, including 7.2% in the production of consumer goods, proved these steps were effective. An export surplus was reached in 1999 ($2.3 billion). Throughout the first quarter of 2000, the GDP grew by 5.5% (including by 3.4% in January and 6.1% in January-February). This trend remained unchanged until the end of the year.

45 Chart 4.2.1. Volume of production and labour productivity in industry in 1997-2000 (in % of the previous year’s rates)

16,5 18 12,9 13 9,6 7,1 8 3,9 4 3 -0,3 -1 -2 1997 1998 1999 2000

Volume of production in industry Labour productivity in industry

Welfare However, the country’s economy is largely affected by a huge foreign debt ($12.5 billion by January 1, 2000). Living standards continue to deteriorate: in 1998, real incomes dropped by 1.6% (about by as much as the GDP). In 1999 the incomes fell by 10.9% while GDP by 0.4%. Naturally, the economic decline affected employment. In 1998, 1,003,200 unemployed people were officially registered, while 1,174,500 in 1999 and there was practically no change in 2000 (1,155,200 thousand). The number of unemployed women increased from 620,400 in 1998 to 730,400 thousand in 2000. The recent years were marked with income and living standard differential between regions; moreover the gaps in income deepened faster than gaps in economic development. The Southeast and Northwest areas are the poorest with the lowest level of self-employment, the most developed ‘in-kind economy’ and labour migration i.e. the areas with the population least adapted to the new economic conditions. The situation is improving in oblasts with relatively low developed shadow sectors, including dacha based agricultural business. As table 4.2.1 shows, the regional differentials of poverty in Ukraine as well as the general level of living standards are quite stable. Thus, according to the poverty criteria established by the government, the poverty level is highest in the oblasts of Lugansk (44.8%) and Mykolaiv (42.6%) as well as the city of Simferopol. It is least high in Kyiv City (10.9%) and the oblasts of Chernigiv (16.1%) and Kharkiv (19.6%). The regional poverty rates and characteristics should be taken into consideration while developing and implementing anti- poverty strategies. Despite the fact that 2000 saw some positive changes in the economy, the trends in poverty have hardly changed. On the contrary, the poverty level and depth increased. The poverty level increased from 27.4% in the first half of 1999 to 28.5% in the first six months of 2000, while the poverty depth from 25.0% to 25.4% respectively. This was the result of the increase in poverty line and further polarisation of the society - the rich became richer while the poor poorer.

46 Table 4.2.1. Poverty by regions Groups of Poverty Poverty Aggregated Correlation of % of Average daily regions by level, % depth, expenditure aggregated population ration poverty level % per adult, income to consuming less (Kilo calories) UAH per aggregated than 2,100 kilo month expenditure, calories a day %

First 45.7 27.2 160.4 139 36.9 2598.5

Second 31.7 24.0 180.0 142 35.2 2706.5

Third 27.1 22.2 183. 141 31.5 2751.7

Fourth 22.1 22.1 202.0 146 27.3 2871.9

Fifth 12.7 17.1 246.8 144 27.6 2853.6

First – Lugansk, Mykolaiv, Sevastopol; Second –Crimea, Volyn, Zhitomyr, Zaporizhzhya, Rivne Ternopil, Kherson, Khmelnytsk. Cernivtsi; Third – Vinnitsa, Dniepropetrovs,k Donetsk, Ivano – Frankivsk, Kirovograd, Lviv, Poltava, Sumy, Cherkassy; Fourth – Zakarpatya; Kyiv Oblast, Odesa, Kharkiv Fifth - Kyiv City, Chernigiv

Certainly, poverty in Ukraine is not a recent phenomenon. Neither is it a result exclusively of the transition crisis nor failures to carry out adequate market reforms. However, today, it the main cause for social tension, decrease in fertility, emigration (including illegal emigration), deterioration of the population’s health conditions and high mortality rates. In Ukraine, there are already conditions for chronic ‘inherited’ poverty, when children from poor families are condemned to stay in misery. They, in turn, cannot offer their children better possibilities and those will stay poor as well. Contrary to popular opinion, poverty was not caused exclusively by the market reforms. Any society can consist of people who for various reasons do not have access to labour, high quality accommodation, education, health care, who have low incomes and whose living standards do not fit the national ones. According to the government’s classification, 27.8% (13.7 m.) of the Ukrainian population should be regarded as poor, 14.2% as living below the poverty line. Comparative analysis for urban areas, small towns and villages shows that the majority of the poor households reside in big cities (36.1%). Roughly the same percentage of those living below the poverty line also reside in big cities.. The poverty differential is conditioned, to a large extent by the local economic structure and the oblast’s geographic location. The high level of inequality is linked to a lack of a middle class, which could have become a guarantor of social stability, progress and civil society institutions. A number of occupations (physicians, educationists, scientists, and engineers) that, at the start of the transformation period, received average (by national standards) incomes and played a stabilising role in society, have found themselves amongst ‘the new poor’. The transfer of a significant number of highly educated and socially motivated people to the group with minimum incomes has negative effects of strategic character. Along with professional degradation and marginalisation of vast masses of people, a great deal of damage has been done to the intellectual and physical potential of society. The new middle class, which has formed in the process of market transition (in particular, due to the privatisation), remains underdeveloped.

47 Subjective poverty The studies conducted by the Ukrainian Institute of Social Research and the Social Monitoring Centre in 1994 – 2000 showed that three in four Ukrainians considered the level of their welfare to be below the average in the country. This is the level of ‘subjective poverty’ showing people’s perceptions of their welfare. Such perceptions are made under the influence of the current trends in the individual financial situation and income differential in society (either real or imaginary). Another factor is the gap between the living standards of most Ukrainians and the living standards in the developed countries as depicted in the mass media. ‘Subjective poverty’ should be taken into consideration while analysing the public’s behaviour and attitudes as it is one of the major factors that contributes to the society’s marginalisation, and it explains the dependence shown by vast masses of the population on the state. This negatively impacts labour activity, kills initiative and desire to seek additional earnings, to be self-employed or to start one’s own business. Dealing with ‘subjective poverty’ requires not only effective economic measures, but there is also a need for strategies aimed at helping the population to adapt to new social and economic realities.

Consumption Level and Structure Lack of money puts many Ukrainian households in a situation when they have to impose limits on nutrition and lack essential consumer goods Throughout 1991-2000, the percentage of household income spent on food increased sharply from 32.8% to 64%, while overall the quality of rations decreased significantly. In 1999, the average daily ration contained 2,505 kilocalories (3,597 in 1990), including 73.4 grams of protein (105.3 in 1990), 71.1 grams of fat (124 in 1990), and 0.848 grams of calcium (1,362 in 1990). 10 million Ukrainians (that is one in five) consume less than 2,100 kilocalories a day (an indicator of the poverty line, according to the WHO). The general degradation of consumption structure has the most serious impact on the poor for whom bread and potatoes remain possibly the only affordable food products. The average cost of monthly ration of the poorest 10% is under UAH 50. They consume 6 times less meat and fish, 5 times less milk, 4 times less eggs, 3 times less vegetables and 10 times less fruit than the richest 10% of the Ukrainian population. Consumption of contaminated food products by majority of the population is another sign of poverty and clean food products are unaffordable for many. Chemically contaminated food causes an increase in number of children born with abnormalities and this trend is expected to continue. Poor diet contributes to the general decline of the health condition of the Ukrainians.

Migration Not surprisingly, migration became a response of the Ukrainian people to low living standards and economic difficulties. Between 1994 and 2000, Ukraine lost 90,000 persons a year. Those were the most qualified and educated people with initiative and skills. Although in 1999 - 2000 the negative migration balance decreased almost twice, the governmental statistics show only the tip of the iceberg. A considerable number of migrants labourers leave the country illegally as Ukraine has become a source of cheap and qualified labour force for many countries of the former USSR and other countries. According to the National Institute of Ukrainian - Russian Relations, there are 300000 Ukrainians migrant workers in Russia alone. More recently, most of the migrants are young people. According to the government statistics, the number of young people between 18-28 years of age who have had some job abroad increased 1.5 times and reached 7,248 in 2000 (81% are men, 19% women). Unfortunately, the “official” statistics record only those who worked there legally. Many job seekers claim another purpose of leaving: tourism, visiting relatives, etc. These are not counted by the Ukrainian statistics, yet they often register in the country of destination and become legal migrants there. Therefore, they are not reachable through information campaigns. According to the data obtained from the Study “The Life paths of the Population of Ukraine”, the number of young people who leave the country seeking employment abroad is 80 times larger than the figure given by the government statistics. Even the estimated figures may not reflect the real situation as some of those who worked abroad in 2000 might have preferred to not disclose this. In particular, the study did not cover those involved in sex industry and those deceived by their employers or mediators and who had to work abroad for miserable sums of money in unacceptable conditions. It is quite possible that the real scale of youth migration is much bigger than

48 demonstrated by the study. For many young people migration plays an increasingly important role as an employment possibility. Thus 81% of those 15-28 year old migrants in 2000, did not have any steady job in Ukraine at the time. Many of small traders (chelnoki) travelling to neighbouring countries are also unemployed (46.6%) i.e. small trade is the only source of income for almost half of those involved and an additional source for the rest. The increase in migration, and trafficking and illegal migration of women are important factors contributing to the expansion of the HIV and STD epidemic in Ukraine.

Religion There is confusion about religion and belief in the Ukrainian society. Those who regard themselves as ‘believers’ may not belong to any church, while those who describe themselves as ‘non-believers’ might, at the same time, feel themselves a part of the denomination in which they were baptised. According to the data obtained from a survey conducted by the Social Monitoring Centre jointly with the Ukrainian Institute of Social Research at the end of 1999, 54% of the Ukrainian young people belonged to some religious faith. Most belong to the traditional faiths for Ukraine: Orthodox Christians (67%), Catholics (15%), Protestants (7%). 1% respondents were Buddhists. However, the situation is very mixed and depends largely on the region and type of settlement: the church is stronger in western regions of the country and rural areas. The activities demonstrated by different religious structures indicate that the issues of sex and drug use are usually not the concern of the traditional Orthodox church. Therefore the role of religious values that might affect young people’s behaviour in the context of the HIV/AIDS epidemic is insignificant at the moment.

Gender relations and violence in the society Today in Ukrainian society, gender inequality manifests itself in many spheres. This is witnessed by a higher level of women’s unemployment, disparities in wages, insignificant number of women in government bodies. Many women experience discrimination at work and violence at home. According to the Interior Ministry, in 1999 alone, 9000 persons were detained on suspicions of committing 11100 crimes against the life, health, will and dignity of women. 10,800 female victims were registered. The common crimes were:

· deliberate murders (1,227 women died); · significant physical damage (1,215 victims); · rapes (1,256 victims) · forcing the victim to have sexual relations in unnatural way (614) · others (6,522)

Sexual harassment is another problem. Research in the field shows that almost every woman experiences sexual harassment at work or home. The victims often had to leave jobs, get divorced or just leave homes, were physically abused, morally humiliated and often faced serious financial problems. One of the consequences is the increase in the proportion of homeless women, many of them young, between 18 and 29 years of age. In 1999, the percentage young women amongst all homeless was 7%. Available sociological data shows society’s attitudes toward the woman’s social role is inconsistent and contradictory. Equality of the sexes is a stated policy, yet the reality is very different. Gender inequality and violence in the Ukrainian society increases susceptibility of women to HIV.

4.3 Attitudes to People with HIV and AIDS in Ukraine38

Analysis of the social context of the HIV epidemic would be incomplete without examining the attitudes of the general public to the problem in general and to infected people, in particular.

38 According to the data from a survey conducted by the UISR in October 1998. Due to the order of the UNAIDS, s section on HIV related issues was included to the questionnaire. 1,1991 respondents 15 years of age and older were interviewed in total. The sample was national, representative by main social and demographic characteristics.

49 Most Ukrainians are aware of the existence of HIV/AIDS. At the same time, there are many myths about the modes of transmission, prevention, testing and so on. This explains the hostility towards HIV infected people. Many Ukrainians say that they would prefer to not deal with HIV infected people in their everyday lives. According to the data obtained from the public opinion poll conducted by the UISR (1998) more than a third (37%) of Ukrainians believe that people with HIV must be isolated in order to prevent the epidemic, the same percentage of the respondents were unsure about this, while only about 25% were against the isolation of HIV positive people. Men showed less tolerance. The idea of isolation for HIV infected people was supported mostly by residents of big cities and small villages. “The European Values Study: A Third Wave’’39 survey provided comparative data on people’s attitudes to those with AIDS. (In Ukraine the survey was conducted in autumn 1999). The findings (see table 4.3.1) show that the Ukrainians are quite intolerant of people with AIDS.

Table 4.3.1 % of those who said they would not like to have an neighbour with AIDS (Source: book of the European Values Study Surveys. –1999, p. 41)

Country % Country % Hungary 78 The UK 25 Ukraine 59 Finland 21 Byelorussia 57 Spain 21 Lithuania 55 Austria 17 Russia 52 Belgium 12 Bulgaria 52 Germany 11 Romania 50 France 8 Croatia 50 Sweden 7 Estonia 42 Denmark 6 Latvia 29 Average for Europe 31

Young people appeared to be more sympathetic 79-86% of young people interviewed expressed willingness to help if any of their relatives and friends fall ill (63-65% of the general population). Support from colleagues and neighbours seems much less likely (39% and 34% respectively). There were different opinions as to whether the state should spend money on prevention programmes. 39% of the respondents were against providing intravenous drug users with clean syringes and prostitutes with condoms (33% supported such programmes), 28% said they did not have any opinion on this matter. The majority of those who supported the idea of harm reduction programmes were young people, especially 18-19 year olds (one in two), who tend to practise risk behaviours and are therefore more worried about the risks of infection. Older respondents tended to be less supportive to such programmes. Certainly, the attitude to HIV positive people directly depends on how accurately people are informed on HIV/AIDS issues. Young people, as a group more vulnerable to the infection, were more concerned about the epidemic and tended to support the state’s efforts to launch effective prevention programmes40. The rapid and uneasy transition has formed an emotional atmosphere of mistrust and hostility typical for a somewhat totalitarian regime, many remnants of which are still in existence in Ukraine. Most Ukrainians demonstrate hostility to their social environment unless it is “people like me”. This is a social and psychological factor on the basis of which xenophobia and hostility to other social groups and nations develop in the Ukrainian society. Changing the emotional atmosphere is crucial for successful reformation of the economy and the society as a whole. Indeed, the role of art, culture and civil society will be equal if not more important than

39 Source: book of the European Values Study Surveys. –1999, p. 41 (in each country there were interviewed not less than 1,000 persons 18 years and older. Natioanl representative sample was used. For more information see: http//evs.kub.ue

40 The HIV/AIDS Epidemic in Ukraine: current situation –?yiv City , 2000 – p.115.

50 the role of economists. Throughout history new ideologies and moral and ethical concepts were reactions toward social conflicts that could not be resolved within the existing ideological, social and mythological concepts The prevailing attitudes from the Ukrainian public is one of stigmatisation towards those infected by HIV or ill with AIDS. Stigmatisation makes the whole country more vulnerable to the epidemic. The spread of the epidemic could become a factor in increasing numbers of young people seeking to emigrate from Ukraine.

4.4. Behavioural factors Contributing to HIV/AIDS Epidemic

Among different behavioural factors that contribute to the HIV/AIDS epidemic in Ukraine, special emphasis should be put on sexual behaviours among the sexually active general population and the groups facing higher risk of HIV-infection. Behaviour that is connected with injecting drug use (IDU) can also increase risk of HIV-infection. Hence, behavioural factors include:

DIRECT FACTORS Sexual behaviour factors IDU factors ? Unprotected sexual contacts ? Sharing injecting instruments ? Casual sexual contacts ? Usage of already used and non-sterile syringes during making, packing, and distribution of drugs ? Starting age for sexual contacts ? Sharing of kitchenware during production of drugs and cleaning of instruments, sharing needles and syringes during injections ? Sexual practices ? Using blood to clean drugs (opiate) ? Partner change rate ? Personal hygiene ? Sexually Transmitted Infections (STI) and self-treatment ? Rituals involving blood INDIRECT FACTORS ? Use of drugs at the sites of drug purchase, parks, hallways, other public areas, in groups. ? Providing sexual services for money or drugs ? Lack of knowledge on HIV and HIV prevention

It is important to examine sexual behaviour factors among the youth, and HIV risk groups: IDUs, female commercial sex workers, men who have sex with men.

Sexual behaviours of young people

Changes in sexual behaviours among the modern youth, young age of first sexual experience, greater public tolerance towards sex prior to marriage, free access of under-age youth to pornography have become extremely important issues in Ukraine. STIs are rapidly spreading among the young population along with early pregnancies and abortions. Sociological data from the Ukrainian Institute of Social Research shows that the majority of Ukrainian youth are sexually active- almost two thirds of respondents (64%) aged 15-22, and 31% aged 15-16 of which 58% were girls and 69% were boys. The risk factor here is the noticeable young age of first sexual experience. Most of the time sexual experience starts between the ages of 16 –18; however among these there are also children who are not ready for sexual experience, neither psychologically nor physiologically: 11% of respondents started their sexual life at the age 14 and 6% between 11and 13. Frequent change of sexual partners leads to risk in sexual behaviour of the youth. Among those who have already had sexual contacts, 43% had from 2 to 5 partners, 25% had 6 and more.

51 Even though young people are well informed on the necessity of using condoms as a preventive method against HIV (73% of respondents), there is a tendency in amongst them to practise sex without condoms. According to sociological data, 66% of young people aged 15-22 who had sexual contacts have used condoms. However, among those who had 3 or more partners in the previous 3 months, about 40% did not use condoms regularly, According to research data, 3% of young men had homosexual experiences – ie anal intercourse with another man. These risky sexual behaviours, together with high levels of drugs and alcohol use makes young people very vulnerable to HIV infection.

Sexual behaviours of men who have sex with men In the course of behavioural studies among men who have sex with men (323 people were surveyed)41 the following data was gathered:

- 31% always use condoms, 21% - never use condoms - 76% have casual sexual contacts - 18% had sexual contacts with IDUs.

Specific research on the lives of sexual minority groups in Ukraine has been extremely rare.

Sexual behaviours of women - commercial sex workers One of the most susceptible groups to HIV-infection are female commercial sex workers (FSWs). An increasing number of women involved in prostitution becomes a major factor in the spread of HIV in Ukraine. The more ‘low income’ female sex workers practise higher risky behaviours. The most vulnerable to HIV infection are those who operate from train stations and the highways especially as most of them do not use condoms. According to FSWs, medical doctors and police, common diseases among sex workers include STIs, tuberculosis, viral hepatitis, and HIV. HIV positive FSWs can be found in every big city in Ukraine. An analysis of sexual services and behaviour with clients revealed the following factors that facilitate the spread of HIV-infection among commercial sex workers: - prevalence of sexual contacts with IDUs - Injecting drug use by FSWs (In Odessa alone, half of the surveyed women reported injecting drug use); - Application of force by clients not to use condoms (cases of using force were registered during the survey); - Voluntary sexual contacts without condoms, is particularly common among the lowest-paid prostitutes who often work for a drug dose. - Widespread practice of purchasing low quality or cheap condoms in commercial kiosks and in market places, fake copies of famous brand names or with expired use-by date.

Sexual behaviours of IDUs (injecting drug users)

Within the framework of HIV/AIDS/STI prevention projects, behavioural studies among injecting drug users42 were conducted in 10 Ukrainian cities. The following behaviour factors of HIV spread were revealed:

- 44-60% have casual sexual partners - 68% practice sex without condoms - 6 to 10% provide sexual services for money or for drugs - 18 to 23% have STIs

41 See:HIV/AIDS surveilence in Ukraine (1987-2000) – p.43 42 HIV/AIDS surveillance in Ukraine (1987-2000) – ?. –2000. – p.41.

52 Behavioural factors that are connected with injecting drug use among FSWs (from interviews with those who work on highways and stationary points in Odessa):

- 30% constantly have sex with IDUs - 22% never use condoms - 44% of those who work on highways use drugs

Behavioural factors among injecting drug users

· use of blood for purifying drugs · use of dirty syringes during drug distribution (dosing): · 80% of drug addicts buy already made drugs · 35-50% of drug addicts buy drugs sold in non-sterile syringes · 68% of drug addicts practise sharing kitchenware during the process of making drugs and cleaning syringes · absence of practice of using disinfectants · the average number of users sharing syringe/needle: 18% share with 2-3 other users; - 15% - with 4-9 other users43

This shows certain behavioural factors to be a bridge between particular risk groups and the general public. The inter-relations between the risk groups and the general population can be illustrated as follows (see: Chart 4.4.1) Chart 4.4.1 Inter-relations of the high risk groups

IDUs-MALE

OTHER MALES IDUs-FEMALE

FSW OTHER FEMALES

MSM

MEN who have sex with FSWs

43 Source: a survey conducted by the UISR and the Ukrainian Youth Social Centre Service among 638 IDUs in 6 cities of Ukraine (August-September, 2001). The survey was conducted within the UNICEF Project «HIV/AIDS Prevention among Young People Using Intravenous Drugs»

53 4.5. Biomedical factors and HIV Susceptibility

Sexual behaviour is conditioned by biomedical factors that include: - virus subtypes - stage of infection - presence of STI - gender

Virus subtypes The world currently knows 2 types of the virus: HIV-1 and HIV-2. The latter is mainly found in Western African countries. In Ukraine, HIV-1 is dominant. In 1997 outbreaks of HIV-infection in Donetsk, Odessa, and Mykolaiv were caused by HIV-1. In Kyiv there are a couple of subtypes of HIV-1. Among injecting drug users the following subtypes of HIV-1 are dominant: in Mykolaiv – subtype B, in Odessa – subtype C, in Donetsk – subtype B and other subtypes, except subtype B. It is considered that HIV-2 and HIV- 1 have similar features and ways of transmission. At the same time there is an opinion that HIV-2 transmits less easily and destroys the immune system more slowly.

Stages of infection HIV-infection develops in different forms and it varies at different stages. There are cases when infected people never get ill, and their infection process is latent for many years. At the same time some symptoms of HIV-infection appear after just a couple of weeks from the moment of infection.

For HIV-infection the following clinical classification exists (HIV-infection: epidemiology, pathologies, clinical indicators. Servetckiy K., Usychenko N., Napkhaniuk V., Gozhenko A. – Odesa, 1999, C.33-34):

1. Incubation period

2. Period of primary symptoms 2?. Sharp stage. 2B. Stage without any symptoms. 2C. Generalised lymphadanopathy (lymph node enlargement) 3. Stage of secondary diseases 3?. Loss of weight by 10%; fungal, viral and bacterial diseases of skin. 3B. AIDS (progressive loss of weight, tuberculosis of lungs, secondary bacterial and viral diseases of internal organs, Karposi’s sarcoma) 3C. Generalised bacterial and viral diseases, pneumonia, lesion of central nerve system, non-typical microbacteriosis , etc. 4. Terminal stage.

The incubation period starts from the moment of infection till the first clinical symptoms of disease and/or presence of antibodies in blood could be between 3 weeks to 3 months, in some cases up to one year. The duration of the asymptomatic stage is defined by the patient’s own immune system. During the terminal stage, the damaged condition of all organs and systems are irreversible.

Presence of STIs There is a proportional relation between STIs and HIV-infection. STIs which cause genital ulcers increase the risk of HIV-infection by 6-10 times. STIs without genital ulcers increase the risk of HIV-infection by 3-4 times.

54 Gender Due to certain biological factors, women are more susceptible to the virus.

Some local biological factors must also be taken into account - those that lead to an increase in risk of HIV-infection. For example, the use of IUDs (intro uterine device) facilitates development of vaginosis and increases risks of HIV-infection by 1.7-2 times. Risk of transmitting HIV-infection during sexual contact with an uncircumcised partner is 3 times higher than with a circumcised partner. However, circumcision is not widely practised among Ukrainian men so this risk analysis does not apply.

4.6. Analysis of influence of regional development factors on HIV-infection prevalence

The influence of the social environment on the level of infection and prevalence rate of HIV can be analysed at the country’s macro-level in general. To do this one can look at the existing index of regional human development which is made of special integrated indices and is based on current statistical data and systematic sampling studies of the situation with public health, education, welfare, and living conditions, and represents the social-economic situation of every region in Ukraine. An assumption has been made for a possible link between integral indexes and prevalence of HIV infection. The hypothesis was formulated as follows: with decrease in values of integral indexes that make index of regional human development, an increase in HIV prevalence can be seen. To test the hypothesis data was used from the regional human development index for Ukraine for 1999 and respective index of HIV prevalence per 100000 people for the same year44. The research included two levels of analysis of relation between HIV prevalence in all regions of Ukraine and indexes of regional human development: - During the first stage of the research, the strength of correlative relations was assessed and analysed. The correlation matrix showed a connection between integral indexes and regional indexes of HIV prevalence. - Based on correlative relations that were discovered during the first stage of the research, a regression model was built to determine the strength of the influence of selected factors on the index of HIV prevalence in regions. As a result of mathematical and statistical analysis it was determined that a noticeable correlation can be observed between the level of HIV-infection and the following integral indexes:

Integral indexes Strength of relation (Pearson coefficient of correlation)45 1 Social environment - 0.518 2 Index of demographic development - 0.441 3 Index of healthcare situation - 0.373 4 Ecological situation - 0.338 5 General welfare of the population 0.49 6 Population’s level of education 0.13 7 Population’s living conditions 0.201 8 Human development financing 0.097 9 Development of labour force market - 0.032

From the above table it is evident that there is a strong correlation between the index of demographic and human development and HIV prevalence rate.

44 See Appendix 1,Table ?1.

45 Correlation coefficients are valid at the level of 5%.

55 The most important outcome of the analysis was a confirmation of the hypothesis about an existence of a strong influence by social-economical development indicators that describe economic, social, educational- cultural parameters, and social environment on the character, level, and rate of HIV spread on regional levels.

4.7 Conclusions

There are a number of factors that might make the economic recovery a long and painful process:

· The increasing foreign and internal debts and new loans most of which will be used for servicing the external debt. · Serious mistakes made in the process of market transition caused a rapid decrease in GDP and economic investment. Moreover, the decrease in investment appeared to be much sharper than the decrease in GDP. Thus in 1999 as compared with 1990, the GDP decreased by 56.3%, while the total investment volume by 78%. The same tendency remained in 2000, which, in turn, is an indication of a degradation of production assets, in particular, machinery and equipment. · Between 1991 and 1999 the investment in science did not exceed 0.1% of the GDP (compared with 1.1% in 1986-1990). In 2001, the state budget allocated UAH 687 million which was 0.36% of the GDP. · The decrease in investment was the main reason for the fall in industrial production. In 1999 as compared to 1990 the total investment into industry decreased 4.2 times, including 17.8 times in the machinery construction and 10.6 times in the production of construction materials. · A catastrophic depreciation of fixed assets in all sectors of the economy was combined with a lack of possibilities for investment. The budget resources are extremely limited, the private sector sees no motivation for investment while the commercial banks are oriented at speculations and reluctant to credit the “real” sector”. Unfortunately, the responsible governmental agencies used different methodology of assessment of production assets and eventually terminated such studies. No governmental statistics are available at the moment. Experts estimate that the wear and tear of the fixed assets reached: § Not less than 70%-75% of the total in the energy sector, and 95% of the power generating facilities; § 60%-65% of the total in industry, including up to 75% of the machinery in ferrous metallurgy, metal machining, machinery construction, chemical and oil refining industries; § up to 80% of the total in the agricultural sector; § up to 55% in the transport sector, including over 80% of diesel and electric locomotives; § 75% of the total in the rail road transport.

This means that in the next 7-8 years, the economy will lose most of its production assets. At the same time, according to experts, the modernisation would cost 2-3 times Ukraine’s annual state budgets. Experts in the Emergency Ministry believe that the situation with basic production assets is a serious risk factor, causing numerous environmental and technical disasters. At the same time, the funds allocated by the government for modernisation are not more than one third of what is needed. Deterioration of the health condition of Ukraine’s general population, in particular children and young people, that is now being observed by medical workers, becomes a risk factor of a national scale. At the same time, in 2000 the state budget did not provide for more than 40% of the estimated need. The same is true for 2001. Recently, some legal acts were adopted in order to introduce a mixed system of funding for the health care sector (state guaranteed medical services together with private paid services and medical insurance). However, it would take 3-4 years to change the situation for the better. Considering the huge demand for investment in such sectors as education, science, culture and other social spheres, one may foresee that overcoming the crisis will be a long and complicated process. This, of course, will have an impact of the spread of HIV/AIDS epidemic in the country. To summarise, the HIV epidemic develops in the context of general social, economic and political processes in the Ukrainian society:

56 · decreasing welfare · growing poverty · growing unemployment, especially among women and young people · expansion of the shadow sector · transition from an authoritarian state to a civil society · intense struggle for power between various political groups · expansion of corruption and power of uncontrolled bureaucracy · inter-regional cultural and religious tensions · high level of labour migration (within the country and abroad) · presence of fairly large number of illegal migrants · decreasing quality of existing medical services · general decline of the public health care system · worsening of the health condition of the general population · criminalisation of the society and higher levels of violence · underdevelopment of leisure facilities for young people · changing values of the society · lack of public trust in the government and social institutions · contradictory legislation · negative attitudes of the general public to people with HIV/AIDS · unwillingness to recognise the HIV/AIDS problem at the governmental level · increased levels of commercial sex · high levels of drug use · outbreaks of infectious diseases (diphtheria, tuberculosis, and cholera) · reduction in life expectancy

The factors listed above characterise Ukraine as a risk society, where a demographic crisis and the social and economic situations increase possibilities for the infection amongst the general population and affects the society’s potential to deal with the epidemic. The inequality between regions might lead to a situation when the epidemic will spread in some areas more rapidly than in other for social and economic reasons.

57 SECTION 5. DEMOGRAPHIC AND SOCIO-ECONOMIC IMPACTS OF HIV EPIDEMIC IN UKRAINE

Based on the analysis of contemporary Ukrainian society, the major indicators of the HIV/AIDS epidemic and projection of the epidemic for the next decade, the factors favourable and unfavourable to the epidemic, and a forecast has been made on some social and economic impacts of the HIV epidemic in Ukraine. The epidemic cannot be stopped: it will develop and affect future generations. One of the features of this disease is that the number of sick people and deaths will grow in the near future. However neglect of prevention programmes might put the epidemic out of control. The impacts of the epidemic will manifest themselves at the individual, family, regional, and sectoral levels. This means that the epidemic will affect individuals, households, particular sectors of the economy, the labour market, the health care system, social infrastructure, the system of social protection, systems and methods of governing the country. It will have impacts upon the level of social tension in society, foreign policy and national security. Adequate and efficient strategies will require analysis of short, medium and long term effects of the epidemic.

5.1. HIV/AIDS Impact upon the Demographic Situation The demographic impacts of the HIV/AIDS epidemic are the most dramatic because the appearance of this critical infection has made the issue of health and life protection really urgent. Ukraine experiences a high risk of HIV infection because, on the one hand, a complex demographic situation (for instance, poor health state of its citizens) is a determinant, which undoubtedly increases the vulnerability of the population to this disease, and on the other hand, the HIV/AIDS spread will further aggravate current demographic trends and impede the normal demographic process development in the future. The demographic forecast drafted for the 1994 – 2010 period, without taking HIV/AIDS into account, had a hypothesis of a gradual, rather low improvement of mortality characteristics in Ukraine. Based on an analysis of the current social and economic situation, with the first signs of stabilization, there is a likelihood that in the coming 10 years Ukraine will have prerequisites which would prevent a further decline in the health state of the population, i.e., the prerequisites for some decrease of mortality rate and increase of an average life expectancy49. In particular, according to this hypothesis, a gradual recovery of the average life expectancy indices to the level of the beginning of the 90’s, or to the pre-crisis level, is expected in Ukraine during the forecast period50. According to the data, in the absence of HIV/AIDS impact, the absolute number of deaths from all causes may reduce in Ukraine by 27,100 in 2001 – 2010. At the same time, if HIV prevalence grows to 2% (best situation) among the adult population by 2010, the number of deaths will grow by 10,200 people by 2006, after which it will decrease slightly. In the worst situation, i.e., if HIV prevalence among adults reaches 5%, the mortality will grow by 47000 people in 2010 compared to 2001. At the end of the forecast period, the absolute number of deaths without taking AIDS into account will be 738,100 people, and taking AIDS into account it may vary from 778,100 to 822,800 people. So, AIDS will contribute 40,000 to 80,000 additional deaths in 2010 alone.

49 The preliminary estimates show that mortality rate indices has started to decrease in Ukraine in 2001. 50 V. Steshenko, O. Rudnitsky, O. Khomra, A. Stefanovsky. Demographic Prospects of Ukraine till 2026. – K.: Institute of Economy of NAS of Ukraine, 1999. – p. 28

58 Chart 5.1.1. Forecast of the Share of AIDS-related Deaths in the Total Number of Deaths in Ukraine during 1994 – 2010, in %.

% 12

10

8 optimistic scenario 6 pessimistic scenario 4

2

0

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 years

Chart 5.1.2. Forecast of Cumulative AIDS-related Deaths in Ukraine in 1994 – 2010, (in thousand people)

500 Acco 450 rding to the 400 forecast 350 calculations, 300 the annual 250 optimistic number of thousand 200 scenario new AIDS 150 cases in the 100 pessimistic best- 50 scenario 0 scenario situation 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 will increase years from 13,160 thousand cases in 2001 to 44,360 cases in 2010. Under the worst scenario, the number of new AIDS cases compared to 2001 will triple by 2005, will grow by more than 5 times by 2008 and will reach 95,210 cases in 2010. The cumulative number of AIDS-related deaths during the whole forecast period (1994-2010) may amount to 307,810 at the best. In the worst case, if there is no successful prevention of HIV spread, the number of AIDS victims might reach to approximately half a million people ie 459,390 people by 2010 (Fig. 5.2.2). Around 60% to 70% of deaths will be among males. It should be emphasised that these numbers of early deaths and excessive mortality should be if not prevented at least minimised.

59 Chart 5.1.3. Forecast of AIDS-related Mortality Rate among Males and Females in Ukraine in 1994 – 2009 (per 100,000 people)

250

men, 200 optimistic scenario women, 150 optimistic scenario men, pessimistic 100 scenario per1,000 population women, pessimistic 50 scenario

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 years

A study of the various factors for AIDS-related deaths depending on age, sex, region and population groups was conducted and it showed some interesting differences First of all, the real age structure of people who died of AIDS in Ukraine between 1987-1999 shows that the victims were mainly young people of the productive and reproductive age. The maximum losses were observed among males and females aged 25 to 34.51 This is confirmed by both the age structure of the registered AIDS-related deaths in Ukraine in 2000 (Fig. 5.1.4 and 5.1.5) and by the projected age structure of those who would contract AIDS in the future. Based on the projection results, most AIDS cases will be seen among males aged 35 to 39 and females aged 25 to 29. Young people of this age will be most vulnerable to AIDS. In particular, the proportion of people of this age in the total number of those who will contract AIDS in 2005 will be around 18.2% among males and 15.5% among females; and in 2010 this will increase to 20% and 16% correspondingly. Secondly, there is currently a gender inequality in Ukraine with regard to AIDS deaths: most of the infected and deceased are males (urban residents). Based on the projection results, most people who run the risk of contracting AIDS in the future will also be males. However, both projections presume a gradual increase in the number of AIDS cases among females which indicates the spread of HIV infection from injecting drug users to the general population. The number of females among people living with AIDS will grow from 31% in 2001 to 46 - 47% in 2010. If in 2001 the number of males living with AIDS is 2.2 times higher than that of females, in 2005 this excess will be only 1.5-1.6 times, and in 2010 this the proportion will be equal. AIDS spread and population mortality related to it will impede and hinder the process of life expectancy growth in Ukraine. Due to the HIV/AIDS epidemics it may decline to 60.1-62.2 among males and to 69.7 – 72.1 among females, i.e., a possible reduction of the average life expectancy varies from 2 to 4 years among males, and from 2 to 4.7 years among females (Fig. 5.1.6).

51 HIV/AIDS Epidemics in Ukraine: Social and Demographic Aspect. – Kiev: Ministry of Health of Ukraine, UNDP, 2000. – p.43.

60 Chart 5.1.4. Chart 5.1.5. Age Structure of People Died of AIDS in Age Structure of People Died of AIDS in Ukraine in 2000, % Ukraine in 2000, persons

60+ 60+ Women Women Age Years Men 50 Men 50

40 40

30 30

20 20

10 10

0 0 100 80 60 40 20 0 20 40 25 20 15 10 5 0 5 10 15 20 25 % Persons

Chart 5.1.6. Projection of the Average Life Expectancy in Ukraine in 1994-2010 (years) * * basic variant – without the impact of HIV/AIDS epidemics

70

69

68

67 Age 66

65

64

63 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Years Basic scenario Optimistic scenario Pessimistic scenario

HIV/AIDS impact on the fertility rates in Ukraine will manifest itself in additional unborn losses, as HIV infected women have lower child-bearing capacity compared to non-infected women. Men and women who will die of AIDS will not become parents. Potential births can also be lost both due to the unwillingness or inability of HIV infected women to become pregnant at all, and due to their refusal to bear children in case of pregnancy, or due to abortions. HIV/AIDS spread in Ukraine can contribute to the increase in unwanted pregnancies, abortions, infertility and worsening of the reproductive health of women in the child-bearing age.

61 A prognosis of fertility rates in Ukraine was made without taking HIV and AIDS into account which suggests that the fertility rate has stabilised in the country, that it will remain at approximately the same level and even grow to some extent in the future. So, a cumulative fertility rate in 2001-2005 will be 1.10-1.13 children per woman, and during 2005-2010 will grow to 1.23. At the same time, the absolute number of births may grow to 430,500 in 2010.

Table 5.1.1. Probable Annual Demographic Losses in Ukraine Due to HIV/AIDS Epidemics in 2001-2010 (thousand persons)

Demographic Including losses of: losses Died of AIDS Unborn Years Best case Worst Best case Worst case Best case Worst case case 2001 17.21 17.1 10.8 10.8 6.41 6,41 2002 23.00 23.2 15.51 15.51 7.49 8.21 2003 28.51 30.3 20.17 20.17 8.34 9.96 2004 34.23 40.9 25.17 28.36 9.06 11.73 2005 39.42 49.8 29.77 36.31 9.65 13.47 2006 43.53 60.67 33.42 45.6 10.11 15.31 2007 46.76 72.67 36.49 55.69 10.27 16.98 2008 48.94 84.87 38.97 66.52 9.97 18.35 2009 50.35 96.75 41.26 77.47 9.09 19.28 2010 51.06 109.03 43.40 89.20 7.66 19.83 Total: 2001-2010 383.1 584.92 294.96 445.39 88.05 139.53

Taking the AIDS impact into account, the cumulative fertility rate will amount to 1.10-1.12 in 2005 and 1.17-1.21 in 2010. The number of births by the end of the projected period can vary from 422,800 to 410,000. Total unborn children due to AIDS will be 88,100 in the best case, and 139,500 in the worst case. The general fertility rate in 2010 will vary from 9.1 to 9.4 born children per 1,000 persons instead of 9.5 children projected without the epidemic impact. So, the demographic losses due to HIV/AIDS epidemic in Ukraine in the next 10 years can amount to 383,000 – 585,000 people through 295000 – 445000 early deaths and 88–140,000 unborn children. According to the results of the projection without taking AIDS into account, the size of Ukrainian population will decline from 47.28 million in 2005 to 45.48 million in 2010. The AIDS impact will result in the population of Ukraine being reduced to 45.09 (the best case) or 44.89 (the worst case) million people in 2010. However, it is important to remember that premature deaths mainly hit the population in the reproductive age group. Negative demographic consequences of HIV/AIDS epidemics will be amplified by a simultaneous increasing in numbers of sexually transmitted infections (STI) which are an important factor for an increased risk of HIV-infection. HIV/AIDS spread will be accompanied by an increase of so-called opportunistic infections and will most probably create conditions for increasing numbers of suicides. Suicide levels in Ukraine are already quite high: they have increased from 20.6 cases per 100,000 people in 1990 to 30.2 cases per 100,000 in 2000. Particularly high rates of suicides have been registered among men: 52.1 cases were registered in 2000 (among women its 10.4 cases per 100,000). High suicide rates in Ukraine call for the need to study this phenomenon within the context of HIV/AIDS epidemic due to psychological trauma and stress of those who are diagnosed with HIV.

62 HIV/AIDS and tuberculosis

In Ukraine particular attention should be paid to the problem of the link between AIDS and tuberculosis. Tuberculosis is a satellite infection of AIDS that develops in a weakened human body. According to different studies, almost every third AIDS patient dies from tuberculosis since HIV infects those cells in a human body that form natural immunity to tuberculosis. Since the early 1990s, a sharp increase in infection and mortality from tuberculosis has been seen in Ukraine. As a result, in 1995 Ukraine declared a tuberculosis epidemic in the country. Age distribution tuberculosis deaths is characterised by a high concentration of those who died in their productive age. In particular, on average 80-82% of men and 68-70% of women with tuberculosis die between the ages of 15-59. In Ukrainian society, people with TB face much less stigmatisation then people with AIDS. Tuberculosis is a curable disease, but if not diagnosed and treated adequately, can result in death. In developed countries, the percentage of those who die from tuberculosis is extremely small. In specific Ukrainian circumstances this theoretically curable disease currently causes almost 11,000 deaths per year. The appearance of HIV/AIDS greatly increases the danger of contracting tuberculosis. And even though the spread of tuberculosis in Ukraine currently follows social conditions, the presence of AIDS increases its public susceptibility, because every patient who has not been cured from tuberculosis can infect 10-15 other people. Apart from this, very often patients with AIDS, especially those in the late stages of the disease, cannot tolerate treatment for tuberculosis. It is obvious that the role of AIDS in tuberculosis-related mortality and infections of population will increase in the future. Even with an improvement in the social-economic situation, AIDS will still be a constant activator of tuberculosis. Because further spread of AIDS in Ukraine is inevitable, the country’s epidemiological situation on tuberculosis will remain unstable in the nearest future and will require constant monitoring.

Regional context

Demographic processes in Ukraine and HIV spread are characterised by a noticeable regional heterogeneity. HIV/AIDS epidemics impact will be largely observed in the southern and south-eastern regions where the worst demographic situation is combined with the highest HIV prevalence rate. These regions are distinguished by the worst indices of living standards, the lowest life expectancy at birth, and the highest losses due to depopulation in the 90’s. Besides, the build-up of the unfavourable epidemiological situation in these regions is influenced by active migration and concentration of refugees and marginalised populations. In the north-eastern and central regions, HIV will manifest itself not only in the direct losses, but also in higher ageing rates. In the Western regions, HIV prevalence rate is the lowest, perhaps due to the predominance of rural populations. Until recently it has been the most demographically safe region, which was a kind of a demographic ‘donor’, as it ‘provided’ for the demographic growth of Ukraine. Today it also experiences the process of demographic ‘pauperisation’. Not only has a crisis demographic phenomenon and depopulation begun to occur, but the migration of productive young people has intensified. In addition economic troubles push them to look for jobs abroad. Illegal women migrants who are knowingly or unknowingly involved in sex-business run a high risk of HIV infection. This migration factor creates conditions for the further spread of this infection in the Western region, which in turn will increase the HIV/AIDS impact on the demographic situation there. Therefore, the HIV/AIDS epidemic in Ukraine that is developing in the background of an unfavourable demographic situation will aggravate existing negative trends in reproduction of the population and increase future demographic losses in the country. Minimisation of these losses and mitigation of the epidemic consequences should become one of the major priorities of the national demographic policy of Ukraine.

63 5.2. Families’ vulnerability Loss of income, increasing poverty The epidemic’s impact upon individuals will increase the possibilities of infection, illness and death. At the same time, the epidemic will affect families. The illness of a family member will mean less input in housework and family budget, and increased expenditure for the family for medical services and medicines, distraction of other family members from work or study. The illness of the bread winner will affect poor families most. Significant data can be taken from current statistics of support provided under the Program of Housing Subsidies. This Program covers all low-income families with children that apply every month for housing subsidies (approximately 750,000 families). The average family size in Ukraine is 2.6 persons. The number of family members in western parts of Ukraine is bigger than in southern and eastern parts of the country. Among the total number of families in Ukraine (14,057,509), single parent families constitute almost 11%. The percentage of families where the father is the only parent is much lower – 1%. Families that consist of mother, children, and one of the grandparents constitute 2% of the total number of families. These types of families represent the most vulnerable groups for HIV-infection (in case of serious illness or death of a breadwinner these families face poverty). As long as the epidemic continues to develop, more and more children and elderly people will be left without any support. That will mean poverty for some types of families. One of the indicators of social security level in society is governmental support of its poorer classes. Low-income and the poor class are represented by almost all types of households: families with children (including families with many children) constitute 43.4% of all poor households, families of retired people– 29.1%, families without breadwinners – 27.6%. Cash income per person, which is the most general indicator of population welfare and a baseline for determining specifically targeted social aid, is 56.0 UAH (just over USD 10) per month. This indicator varies greatly from region to region: in central, western regions of Ukraine and Crimea it is 44.5 – 49.0 UAH, in southern regions and in Kiev oblast it is 61.0 – 70.5 UAH. One of the most difficult problems for poor families is unemployment. Among those surveyed almost 24% of families had unemployed members. In turn, the presence of unemployed people decreases level of monetary income. Poverty among population increases because education, culture, and health have become paid services. Inflation, increases in costs for rent, utilities and consumer products, unemployment and delays in salary payments place an enormous financial burden on families. This could lead to an increase in HIV-infection susceptibility. Efforts at HIV prevention are adversely affected by poor family living conditions and ways of life. Together with this, premature mortality among men at their marriageable age negatively influences marriage-family and child-bearing situations. Incurable illnesses and the loss of working capacity of a spouse as a result of AIDS, increases the probability of divorce and the number of widows and widowers. The presence of an HIV-positive person increases psychological, physical, and economic load on the family, contributes to family tension and conflict situations, increases responsibility for family survival particularly on women and older people. The existing pension system does not have a direct relation between working contribution of a person and the amount of his/her pension. 96% of all retired people receive pensions that are below the poverty level. Very often adults contribute to the income of their children’s young families and support their grandchildren. Apart from this, it should be mentioned that susceptibility towards HIV-infection is higher among urban population than among those who live in rural areas as conservative traditions still strong in rural areas. However, people in rural areas have less access to HIV prevention education in comparison with those who live in towns and urban cities. This can be attributed to the absence of adequate number of relevant institutions including NGOs and accessibility of medical services in rural areas. From this point of view, people in rural areas are more vulnerable to HIV-infection. Most of the HIV prevention programmes target the urban population. But the rural population is also at risk. Development of strategies targeting the rural population will take some time through which the epidemic will spread in rural areas. This means there will be a greater need for resources to deal with the epidemic and its

64 impacts in rural areas.

Orphans One of the consequences of the AIDS spread is an increasing number of orphaned children who lose their parents due their illness. In Ukraine there is no official data on children that have lost one of their parents (or both) due to AIDS. “AIDS orphans” is one of the most serious social consequences of the epidemic. Based on WHO estimates, in 2000 globally there were almost 10 million (up to the age of 10 years) who had been orphaned because of AIDS52. According to data from the State Committee for Statistics, at the end of 2000 there were 44 orphanages in Ukraine, with total of 12,254 children. While children who lose their parents due to AIDS suffer just as all other orphans, their psychological condition is worsened by the stigma they face. This can result in them dropping out of school and not receiving necessary medical support. Increasing numbers of AIDS orphans are deprived of parental guardianship and this can lead to an increased crime rate. The prognosis is that the number of orphaned children in the year 2010 can reach in the best case scenario to 46,370 thousand. In the worst case scenario it could be as high as 77,36053 (see Chart 5.2.1). This will result in a serious additional load on the system of social welfare in Ukraine. An increasing role and responsibility on the adult population for care and support for grandchildren that become orphans is also predicted. Currently, extremely low level of pension support results in a situation when working people are forced not only to support their children, but also to take care of their old parents. In cases of death of young people from AIDS, their parents will be left without financial support and care in their old age. HIV/AIDS epidemics can also lead to change in family structures by increasing the number of people who need support and at the same time, a decreasing number of employable family members. This, in turn, will influence the level of financial security, nature of expenditures, successful socialisation of young generation, and so on.

Chart 5.2.1. Prognosis of the number of orphan children in Ukraine during 1994-2010 as a result of death of one or both parents that had AIDS (in thousands).

90 80 70 60 50 ???Best??? case ??????? 40 ??????Worse ??????? case thousands 30 20 10 0

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 years

52 AIDS: shapes of epidemics. –WHO. –1994. –p.36 53 According to data of the Ministry of Education and Science of Ukraine, as of 1999 in Ukraine there were 103,4 thousand. Orphan children and children without parental support. // State report «Situation with children in Ukraine at the end of 1999. Social security for orphan children and children without parental support. - ?., 2000. - P.18.

65 The long term problems of such orphanhood will be:

· a considerable increase in the budget expenditure for care establishments · the need to ensure adaptation of a large number of orphans to independent living · the provision of adequate education and professional training · the provision of accommodation and other resources at the initial stage of independent life · support services to provide orphans with social, psychological and information support

Care provision for HIV infected orphans will be particularly expensive. This means that a new structure of social support has to established and then supported and developed.

Therefore, the main factors of family HIV susceptibility are: · Family composition and number of children · Presence of older adults who need support · Housing conditions · Level of expenditures for food · Presence of unemployed people · Financial capacity (medical services, education) · Location (region of Ukraine)

Family vulnerability can be seen through the following: · Increase in the number of families with only one parent · Increase in the number of orphan children · Increase in the number of families of retired senior people · Financial capacity (medical services, education · Location (region of Ukraine)

As a result of insufficient financial resources and poverty, families create HIV-infection high-risk groups. This is particularly true of socially challenged families (drug addicts, alcoholics, etc.). Vulnerability amongst these groups will manifest itself through: · Increase in the number of orphaned and homeless children due to the deaths of their HIV infected parents. · Damage of physical health and mental state of children who are being brought up in poverty and unhealthy environments . · Increase in the rate of sexual contacts among adolescent and young children that poses risks for health and life if infected with HIV · Increase in the number of “social” orphans (with parents alive). Such children are totally dependent on the Government for their education and future jobs that require substantial financing. Besides, such children in their growing years are deprived of parental love and care, and thus become unsatisfied and are likely to develop anti-social behaviour.

Some parents may abandon their HIV positive children. There are already 150 such children living in institutions. The increase in number of HIV infected orphans will create additional problems for state health, educational and social agencies.

The epidemic will have the following impacts upon children:

§ Children will have to take on the responsibilities of adults § Older children will have to leave education early and begin to work § Younger children will lack parental care: fostering remains underdeveloped in Ukraine (by the end of 1999, the foster children homes in Ukraine contained 762 children, but in 2001, only 49 children stayed in foster

66 families). § Children might lack food and other basic necessities. § Brothers and sisters might be separated after the parents’ death and be placed in different institutions or families. § Some children will be abandoned by their parents because of their HIV status.

5.3. HIV/AIDS impacts upon economic activity of population

During the last few years the difficult situation in the labour-market has been worsened and has resulted in decreased levels of job placements and at the same time increased levels of unemployment amongst the population. The number of economically active people aged 15-70 years at the beginning of 2001 is as follows:

Table 5.3.1 Population based on economic activity, sex, and place of residence On average for 2000 In thousands % prior to 1999 Economically active population aged 15-70 years old. 23127,4 101,7 Including: Employed 20419,8 101,9 Unemployed 2707,6 100,3 Economically active women aged 15-70 years old. 11230,8 102,0 Economically active men aged 15-70 years old. 11896,6 101,4

The majority (88.7%) of economically active population aged 15-70 years old is employed in a wide range of sectors. Results from a survey state that unemployment is more common among men than among women - 11.9% and 10.8% of the economically active population respectively. Every third unemployed is 20- 29 years old, every fourth is 30-39 years old. And these are the age groups with the highest number of registered HIV-positive people, both women and men. Also, 766,700 people (or 3% of economically active population) are unemployed citizens who have given up hope of ever finding a job. This is a population facing a high HIV risk. The projected figures with regard to the AIDS situation among productive population shows the following picture: according to the optimistic scenario, by 2005, 89.3% of all patients with AIDS will be people in productive age (15-59 years). According to the pessimistic scenario, by 2005, 92.6% of all patients with AIDS will be people in productive age. It is important to remember that the epidemic will have effects in both “official” and informal sectors. Given that the shadow sector is largely hidden, it is difficult to assess the effects in that area. What is certain is that the epidemic will affect the informal sector which provides economic sustenance for many Ukrainian families.

5.4. Susceptibility and vulnerability of some economic sectors

HIV/AIDS epidemics do not have any boundaries or borders and spread at all levels and across all economic sectors. The age structure of HIV-infected people, those who live with AIDS, and those that die of AIDS shows that the economy loses most productive labour force with high level of professionalism and specialist training. Senior personnel are not capable of replacing young people, since their educational and professional level might be of a lower standard; at the same time young professionals lack experience that the old personnel have. Therefore, there will be increased spending on improving levels of qualification of labour force.

67 HIV greatly influences development and functionality of economic sectors.

Main factors of HIV vulnerability in the economy are : · Absence of an employee from workplace due to illness . · Absence of an employee from workplace to care for the sick, attendance at funerals . · Death of employees · Disturbed emotional state of employees: fear for getting AIDS, losing colleagues. · Disturbed situation at the workplace: discrimination against HIV-infected people, additional loads on employees due to loss of personnel. · Loss of qualified employees · Decrease in population that is able to work productively · Increase in expenditure for re-recruiting and training additional labour force · Decrease in quality of labour · Cost of medical services, insurance, handicap compensation, etc. · Difficulties with scheduling and management of work · Tense relationships between employees and employer

Main factors of HIV susceptibility in the economy are :

· Gender inequality in some areas of economy · Inadequate level of social security of the population · Migration · Environmental degradation

The epidemic will cost even more if the cost of care and compensation is also taken into account. If an employee receives a salary and pays for medical services, insurance, and house utilities himself (or waits till the State pays all his bills), then the impact of the epidemic is not so great for his/her company. However the impact will be felt later, when State expenditures increase and the company will have to face additional taxes. If a big company pays for medical insurance, medical treatment, and other social privileges, at some point it will be forced to either incur substantial expenditures or decrease the amount of payments. In Ukraine, there has been an increase in the number of self-employed entrepreneurs and small family businesses. Also, the number of companies and family farms that are being managed by young businessmen is increasing. One can notice the spread of HIV-infection in this sector. There are a number of reasons for this. Firstly, these groups of people have the income that allows them to purchase expensive narcotic drugs. Secondly, such people have a wide and diverse social environment and may have multiple sexual partners including commercial sex workers. Apart from this, they often work under psychological pressure and in order to relax might use drugs or visit sex workers. The spread of HIV/AIDS epidemics in such economic sectors as construction and transportation services have their own characteristics. In the construction industry, the following factors facilitate the spread of epidemics: · Work sites are often far from the homes of the labourers · Temporary housing for workers · Few opportunities for leisure and entertainment.

Employees in the transport sector, long distance truck drivers in particular, are also susceptible to HIV- infection. They too spend a great deal of time away from home and often for long periods. Many of them have frequent contacts with commercial sex workers on the highways, who in turn are often injecting drug users as well.

68 When this unqualified labour force faces illness (most of them are migrants), companies will lose their employees and consequently the quality of work will suffer. If the epidemics progress among these categories of workers there is a danger of losing highly skilled and experienced workers.

The social and economic effects of the AIDS epidemic depends on how the growth in infections and mortality of population influences the social and economic potential of society and the population. Also, some regions could be more susceptible to the epidemics through the influence of negative socio-economic factors. These are regions that experience economic decline. The biggest concentration of vulnerable families can be expected in highly industrialised regions of Ukraine such as Donetsk, Dnipropetrovsk, Lugansk, Zaporizya and Kharkiv. An integrated approach to working with these populations requires substantial additional resources and efforts.

At the level of enterprises, vulnerability will depend on the quality of labour force that fall ill and consequently leave the work force. Training of mangers and qualified workers requires time, skills and experience. This means that the cost of recruitment, training, and social insurance of the employment market will increase.

69 5.5. Social support and social security to HIV-positive people

According to the data of the Ukrainian Centre for HIV/AIDS Prevention between 1987 and 2001, 43,600 HIV-positive people were officially registered in Ukraine. Unofficial data shows that in reality number of HIV-infected people is more than 10 times higher. This is closer to the estimated data through this study. Projected estimates made by best and worst case scenarios are shown in the Section 3.1. As the above data shows, the number of HIV-positive people will continue to increase and in 2010 there might be 289,000 HIV-infected men and 293,000 HIV-infected women (best case scenario) or 720,000 HIV cases among men and women collectively (worst case scenario). This requires an urgent response for the development and implementation of an integrated strategy targeted at this population group. Few countries in the world have a unified social and medical policy for HIV-positive people. Ukraine currently does not have such a policy. It is important to understand that it is not HIV-positive people themselves but the absence of a co-ordinated and effective policy in dealing with them that carries a threat for the population.

According to numerous social studies in the field and the experience of clinicians and NGOs, the main social problems of HIV-infected people in Ukraine are:

· lack of anonymity of HV test results · relations with family members, relatives, friends · work relationships and possibility of losing one’s job · housing conditions and financial situation · legislative issues and relations with the state and legal bodies · discrimination and stigmatisation · access to drugs and medical treatment in general · access to financial and physical help from different people, organisations or services. · violation of human rights of HIV positive people

Characteristics of the main problems of HIV-infected people

Confidentiality of HIV test results

Confidentiality of HIV test results is the most important issue since, as experience shows, neglecting confidentiality leads to other problems. It is specially important that confidentiality should be observed when a person is tested as HIV-positive during a general medical check-up rather than when specifically for HIV test. Betrayal of confidentiality results often in HIV-positive people losing their jobs and friends, and sometimes they are even forced to leave their families. So, the lives of those whose HIV test results remain confidential greatly differ from those whose results were made public.

Relationships with family members, relatives, friends, and colleagues

Most Ukrainian citizens know very little about HIV and its modes of transmission. This leads to prejudices and sometimes hostility towards HIV-positive people who become socially isolated. Almost no one follows principles of confidentiality and soon the HIV status of a person becomes public. Most of the times this leads to break-up of families, loss of friends and employment. Also, given that the

70 majority of HIV-positive people use drugs or belong to other risk groups, their social isolation leads to further marginalisation. Families of HIV-infected also feel social pressure and often become outcasts.

Means of survival and housing

According to Ukrainian legislature, HIV-positive people have a right to housing and monetary benefits but in reality this help is quite hard to receive and the financial support is negligible. Therefore, losing social contacts and sometimes jobs leads to situations when HIV-positive people are left without any means of survival. Besides, most HIV-infected people have dependants (children, parents, relatives) who need constant financial support. Therefore, the spread of the epidemic will have a negative impact of families and households. Solving housing problems through providing HIV-positive people with separate households is unlikely to happen in the nearest future. But there are possibilities for providing homeless HIV-positive people with hostels or other similar facilities. There are no state programmes for providing people with HIV/AIDS with accommodation. The housing sector is largely commercialised while state provisions hardly exist. At the moment the government is unable to implement even the existing modest programmes of accommodation to some disadvantaged groups, such as young people leaving care institutions. Many Ukrainians (in urban areas especially) live in privatised flats. At the same time, most of the employed Ukrainians can not afford to buy a flat or a house.

Discrimination Many HIV-infected people face problems with representatives of the law enforcement, agencies and with prospective employers. It is extremely important to improve current legislature that regulates relationship of this category of people with governmental bodies, law enforcement, and healthcare. According to expert estimation, the number of employment rejections due to HIV status, as well as prosecution based on HIV status are issues that must be addressed and resolved as soon as possible.

Absence of medications and quality medical treatment HIV-infected people need special attention from medical workers and other healthcare personnel. Even when they know about their HIV status, they very rarely visit psychotherapeutic services. Experience shows that almost one third of HIV-positive people receive general health care free of charge, but the rest do not have access to drugs. Apart from the cost, absence of adequate information on proper medications that are used in treatment of HIV-positive people also influences availability of these medications. In order to improve the quality of medical services, additional funding is required for the healthcare system and highly qualified medical personnel. The Government has declared its intentions to support people with HIV/AIDS and has declared 2002 as the year to fight AIDS. Since the HIV epidemic began in Ukraine, 23 regulations in the field have been adopted. Ten of them were issued by the Committee on Combating HIV/AIDS, the work of which was supervised by the President of Ukraine (the committee was reorganised a few times and finally dissolved as ineffective). Five documents are on financial support to families with HIV positive children. Unfortunately, the allowances they provide are extremely low. Two more are instructions for testing laboratories. One regulates HIV positive persons in penitentiary institutions. Additionally, there is an agreement on research co-operation with the CIS states; the decree on the establishment of the clinic centre; and possibly the most important one, the Law “O n AIDS Prevention and Social Protection of Population”. Article 4 of the Law reads: “The state guarantees availability, quality, and efficiency of medical examination, including anonymous examination and pre- and post-test counselling.” Article 7 stresses that “medical examination should be voluntary”. In reality these rarely work. The health care sector is generally unprepared to deal with the epidemic while the state does not have money for substantial improvement.

Financial help and support of social environment There are three main sources of help for HIV-infected people: • international aid

71 • governmental help • self support services

International aid includes supplies of medications, clothes, food, funding of different projects. However the amounts are relatively small in comparison to the needs of HIV-infected people. In Ukraine, the social work profession who could provide care for HIV-infected people is not yet institutionalised. However preparation of qualified social workers is being conducted in different educational establishments, including institutions such as School of Social Work at the National Academy of Kyiv-Mohyla Academy where students and faculty members have frequent contact with HIV-infected people and self-support groups. The All Ukrainian Network of People living with HIV/AIDS is a self support group established to unite people with HIV in Ukraine. This network has representative offices in 17 regions of Ukraine and has more than 200 members. So Ukraine already has some experience of fighting HIV/AIDS epidemic with the efforts of HIV-infected people. But the ability to solve the problems of HIV-positive people to a large extent depends on the State. It is expected that the country will organise medical help for those who need it.. The protection of interests of HIV-positive people and those who already live with AIDS is being provided through: - system of State and private insurance development of special funds that will raise money from different sources - targeted guaranteed support from international organisations of those structures that provide prevention education, diagnostics, and treatment of HIV-infection. The nature of the existing problems of HIV-infected people in Ukrainian society calls for two approaches in finding solutions: External – based on waiting for help from governmental institutions and international organisations Internal – based on understanding the importance of the active role of HIV-infected people themselves in solving their own problems. In current Ukrainian conditions, the external approach in solving the problems is predominant. The Human Rights of HIV-positive people and those living with AIDS are regulated and protected by the Constitution of Ukraine and Decree on "Prevention of AIDS and social security of population " signed on December 12, 1991. Articles 8, 12, 17-19, 25, 32 of this Decree guarantee confidentiality, freedom rights, rights to housing, equal medical treatment, etc. The Decree also envisions compensation for intellectual and financial losses due to violation of these articles. The Cabinet of Ministers of Ukraine has approved a number of normative documents that directly influence quality of life of those who live with HIV/AIDS. Among these documents – Decree of the Cabinet of Ministers of Ukraine N1051 of 10.07.98 “About the amount of monthly state aid to children up to 16 years old that have been infected with HIV and those who already live with AIDS” according to which monthly financial aid per child is 34 UAH. The problem of HIV-positive babies that are left without parental support remains unsolved. They spend a lot of time in maternity hospitals or in infectious diseases departments of children’s hospitals that act as orphanages. Therefore, the primary tasks for solving problems with HIV-positive children are: · Saving lives of children who are born with HIV-infection · Provision of an adequate living standards for children, ensuring their psychophysical development and socialisation. · Ensure confidentiality of test results of a child during his/her transfer to other institutions Currently the situation with HIV-positive people is even more complicated given:

72 · the absence of affordable preventive treatment of HIV-infected people, including pregnant women with antiretroviral medications (the programme of anti-retroviral therapy has only recently begun) · the absence of adequate medical support for people living with HIV/AIDS, including preventive treatment (combination therapy) · the restricted access to medications for prevention and treatment of opportunistic diseases, including research on viral load level on immune functions · the absence of social rehabilitation systems for people living with HIV/AIDS, including young mothers. · insufficient social support of children who are born HIV-infected

Therefore, the needs of those infected with HIV or living with AIDS are not confined to problems with medications and medical care. They also need social support and protection from the society. This requires development of a comprehensive strategy for supporting HIV-positive people. UNAIDS has developed the main strategic directions that can be used at the State level:

? Resource mobilisation ? Availability of voluntary HIV testing and counselling ? Availability of psychological and social support services ? Improvement in the quality of medical services ? Availability of treatment for HIV-positive people ? Development of a supportive environment.

73 SECTION 6. PREPARADNESS OF THE HEALTH CARE SYSTEM TO DEAL WITH HIV/AIDS

The social and economic transition has caused a deep crisis in Ukrainian society and, in particular, in the field of health care. The factors contributing to the decline are many: market transition, radical changes in society in general, the falling GDP, budget deficit and a lower capacity of the state to provide adequate health care for the population. Today, the state funding for the health sector is half of what is needed for the system to function effectively54. Over the last three years the GDP has grown, while allocations to health care have increased. 3.8% of the GDP was spent on the health sector in 1998, 3.5% in 1999, and 2.8% in 2000.

Budget expenditure on health care in Ukraine

Year 1998 1999 2000

Average exchange rate 1$ to UAH 2.0 4.5 5.4

GDP (projected) UAH mln. 101,100 112,000 150, 800

State budget, total, UAH mln. 24,481.8 25,135.3 27,327.3

Consolidated budget of the health care system, total, UAH 3,862 3,917 4,298.9 mln.

% of the state budget 15.77 15.58 15.73

% of the GDP 3.82 3.50 2.85

In 2000, the consolidated budget of the health care system was some UAH 4,298.9 mln, which was 2.85% of the GDP and 15.7% of the state budget. The Health Ministry received some UAH 296.93 mln. From the state budget, this was 11.54% more than in 1999 and constituted 48.2% of the total expenditure for the health care system. According to the World Bank the state allocations in the health care sector has reduced by 51%. The lack of funds is severe to the extent that many state medical establishments lack basic medicines and medical equipment and often have to delay payment of staff. salaries The private medical sector does not compensate for the losses in the state sector. Salaries do not provide for expenditure for health care, which makes private medical services too expensive for many people. The general situation in health care could be illustrated as follows: decrease in quality of medical services leads to worsening health conditions of the majority of the population which in turn causes a drop in life expectancy. The health care system suffers from the general financial instability in the country, which actually caused a collapse of free medical care in the country. Recently, the government cancelled the right of state medical clinics to provide some paid services and imposed a tax on profit obtained by medical establishments through renting out their premises. The Ukrainian health care system does not appear to be prepared for the HIV/AIDS epidemic. Most Ukrainian clinics are poorly equipped and understaffed, especially in rural areas. There is a severe shortage of

54 HIV/AIDS Epidemic in Ukraine: the current situation. – ? yiv City , 2000. – p.72

74 testing equipment. Many clinics are incapable of providing even basic treatment not to mention prevention services. The situation with paediatric services is most critical. Today, HIV/AIDS has become a subject of numerous medical, social and other studies in Ukraine. They all show that the south east industrial zone is the worst hit; the rural population to be least provided with medical services; and the male population in the productive age group to be most susceptible to infection. A new strategy of HIV testing has been developed in order to improve the current system of monitoring the epidemiological situation in the country. This new strategy provides for the following principles: · Voluntary and anonymous HIV testing · Confidentiality of information obtained within pre-and post-examination counselling · Providing HIV positive patients with medical services and conditions on a par with other patients in the country · Availability of protection and disinfecting materials · Educational and information campaigns · Compulsory pre – and post test counselling

However, these principles do not always work in practice. The main reasons are the high cost of HIV testing, the underdevelopment of the testing network and the inexperience of the medical staff. The latter means that many medical workers in the HIV/AIDS field are simply not trained to deal with specific HIV issues and even psychologically are not prepared to deal with the problem. Despite the fact that the Law provides for mandatory pre and post examination counselling, a qualified counsellor is still an exception. Moreover, the Ukrainian health care system provides very few services aimed at young people, especially those in risk groups. Exclusion of young people is another factor contributing to the epidemic. To improve the situation a network of youth friendly clinics was launched.55 These were created to provide counselling and medical aid for STIs and counselling on HIV prevention At the moment there is no up-do date treatment for HIV/AIDS in Ukraine. Lack of funding has resulted in a severe lack of properly equipped clinics, qualified medical staff and effective drugs. Today, an HIV positive patient can obtain imported drugs only at his/her own expense. Also, there are no state social services for people with HIV and AIDS. A decree of the Health Ministry lays responsibility of HIV/AIDS treatment on oblast (city) AIDS centres and clinics for infectious diseases (for non-IDUs), narcological clinics (for IDUs), and TB clinics (for patients with active form of tuberculosis). At the moment, City AIDS Centres have been launched in 18 big cities of Ukraine that have high HIV infection rates. The medical staff there often have to work as psychologists, social workers, patients’ friends and priests. The question remains about the impact of this on the quality of the medical service. The public health sector will be the first sector to face the effects of the epidemic. The demand for AIDS treatment will be an additional burden on the medical services which already fail to provide adequate aid to the nation. How many people will fall ill and to what extent will the existing health care system be able to help them. AIDS treatment is extremely expensive and in Ukraine, the annual treatment course per patient costs about $ 8,000-10,000. One HIV tests costs $5, a DNA test could cost from $100 to $200. An epidemic projection (see Section 4) might be helpful in order to assess the potential burden for the health care systems

55 The first youth friendly clinic was piloted in Kyiv City in 1998 as part of an agreement between the Health Ministry and UNICEF.

75 According to the optimistic scenario, the total number of HIV infected people will reach 430,000 in 2005, while 580,000 in 2010. That means 0.18% of the adult population will be infected by 2005, while 0.2% by 2010. The annual incidence will reach 31,690 cases in 2005, while 44,360 thousand in 2010. Men are at higher risk. 12,260 new cases among women is expected in 2005 and 20,790 in 2010, while the corresponding figures for men will be 19,440 and 23,570. The projected AIDS mortality be 29,770 cases in 2005 (that is 0.63 per thousand population), and 43,400 by 2010 (0.96 per thousand population). The pessimistic scenario is much more alarming: 780,000 infections are expected by 2005, and 1,440,000 by 2010. The HIV prevalence in the adult population is expected to reach 0.5% in 2005, and 0.6% in 2010. The annual number of new cases might reach 40,610 in 2005 and 95,210 in 2010. The male/female ratio will be as follows: 15,930 new infections among women are expected in 2005, while 44,290 in 2010. In 2005 the incidence rate for men may reach 24,680 in 2005 and 50,920 in 2010). AIDS will cause 36,310 deaths in 2005, and 89,200 in 2010.

Optimistic Pessimistic In 2005 In 2010 In 2005 In 2010 Overall number of HIV infections (thousand 430 580 780 1440 Percentage of the adult population infected: 0.18 0.2 0.5 0.6 New cases yearly in the adult population (thousands of persons): 31.69 44.36 40.61 95.21 Men: 19.44 23.57 24.68 50.92 Women: 12.26 20.79 15.93 44.29 Annual AIDS mortality Total (thousand persons): 29.77 43.40 36.31 89.20 Cases per thousand population: 0.63 0.96 0.77 1.99

The projected figures of HIV and AIDS cases and AIDS related mortality show that the current situation is extremely serious. Urgent measures are therefore at the national level are required in order to get the epidemic under control. The epidemic will inevitably expose the existing problems in the field of health care.

Whichever scenario becomes a reality, there will be an explosive increase in spending on: · HIV diagnostics · Treatment and care for patients with HIV and AIDS · Treatment for opportunistic infections associated with AIDS · Prevention of vertical transmission · Prevention among risk groups

There will also be a rapid increase in the demand for: · Highly qualified medical staff (and their training and re-training) · Testing laboratories · Test systems · Counselling centres · Hospitals · Social services · Services for psychological support and rehabilitation · Educational and information prevention programmes

The problems of inequality in the provision of medical and social services between urban and rural areas; availability of testing systems and medical facilities in general; provisions for AIDS treatment; and

76 socio-psychological rehabilitation of patients with HIV/AIDS will be highlighted. The epidemic projection below seeks to analyse the potential budget expenditures associated with the epidemic.

Optimistic scenario Pessimistic scenario 2005 2010 2005 2010 Spending on AIDS treatment (UAH million.) 177.49 248.44 227.43 533.19 % of the Health Ministry’s budget spent on dealing 16.9 22.6 21.7 48.5 with the HIV/AIDS epidemic Occupancy level (million days per one hospital bed) 1.14 1.60 1.46 3.43 % of hospital beds needed 0.9 1.3 1.1 2.7

These figures demonstrate that even if the situation develops as predicted by the optimistic scenario, the cost of HIV/AIDS treatment will grow sharply, involving more funds in the entire health care system. By 2010, these costs will exceed one fifth of the total budget of the Health Ministry. If the pessimistic scenario becomes a reality, the costs related to the HIV/AIDS epidemic will be require almost half of the total budget of the Health Ministry by 2010. Therefore, in the field of health care alone the cost of the epidemic may prove to be unsupportable. In order to mitigate the HIV/AIDS impacts in Ukraine, the following measures are likely to be needed:56 · The Law On AIDS Prevention and Social Protection of Population should be backed up with sufficient financial and other resources from the state budget · The programmes aimed to provide each person with options for voluntary anonymous HIV testing, counselling in order to prevent the infection, and support for patients with HIV need to be continued · A systematic prevention of vertical transmission needs to be launched and implemented. It could be incorporated into the already existing programme of reproductive health care and become a component of the programmes for supporting mothers with HIV

Based on the above points, it is imperative that the state needs to respond urgently to a growing crisis. A key step would be the formulation of an inter-sectoral co-ordinating body responsible for: · Monitoring the epidemic · Treatment and care for people with AIDS · Training of the medical staff · Informational campaign

As the problem of HIV/AIDS is multi-faceted, a range of ministries and departments should be involved in dealing with the epidemic. At the moment, the following institutions are involved in the response to HIV/AIDS: Department of Socially Dangerous Diseases and AIDS at the Health Ministry; Ukrainian AIDS Centre at the Gromashevksiy Research Institute on Epidemiology and Infectious Diseases. At the national level there is the Governmental Commission on HIV/AIDS Prevention. Experience from other countries shows that executive inter-sectoral agencies with wide powers are most effective in dealing with HIV/AIDS epidemic. It is important to assess realistically the medical services available to HIV infected patients. Such an assessment would contribute to the development of a more efficient and economically feasible system for treatment and counselling. Strategic planning is needed in order to develop a national scale framework of HIV/AIDS prevention and dealing with the epidemic’s impacts.

56 Strategic planning for national response to the HIV/AIDS epidemic

77 SECTION 7.

HOW TO ORGANISE AN EFFECTIVE RESPONSE TO THE EPIDEMIC?

There is strong evidence that the number of HIV and AIDS cases and AIDS related deaths is growing steadily in Ukraine. The transition in Ukraine is accompanied with expansion of drug and sex markets which in turn leads to an expansion of STIs, HIV and tuberculosis. Today, the government considers HIV/AIDS prevention as one of the priorities in the health care system57, although of course the problem is not purely medical. The HIV/AIDS epidemic in Ukraine has coincided with a severe social, economic and demographic crisis. As stated earlier, the demographic impacts of the epidemic might strongly affect the country’s social and economic development. The epidemic will however spread in spite of all attempts by the government to control it. The reasons are as follows: · Lack of sufficient funds · So far, the public has failed to realise the scale of the problem. The epidemic is still being considered as something affecting isolated groups · The high-risk groups (IDUs, FSWs, convicts, etc.) remain highly stigmatised · The general population remains under- or misinformed on HIV/AIDS and prevention techniques · There is a lack of sufficient co-ordination between agencies responsible for HIV/AIDS prevention strategies · There needs to be established a governmental agency responsible for co-ordination between all organisations involved in the HIV/AIDS prevention · The staff involved in the harm reduction programmes for intravenous drug users and female sex workers do not receive appropriate training · The medical provision for people with HIV and AIDS is very inadequate

The projection of the HIV/AIDS epidemic in Ukraine is based on the optimistic scenario of demographic development until 2010 as well as the optimistic scenario of economic development. The projection of economic and social situation was based on the assumption that the country would manage to overcome quickly the current deep social and economic crisis. The optimistic scenario of economic development would only be possible on the basis of a comprehensive programme of the state system and economic development proposed by the President and the Government of Ukraine. However, economic and social development of the country might follow the negative scenario, which in turn, would complicate the situation with HIV/AIDS in Ukraine. Currently, the main document outlining the prevention strategy is the Law of Ukraine On AIDS Prevention and Social Protection of Population in its new version of March 3, 1998. In accordance with international law and the recommendations of the World Health Organisation, the Law provides for legal regulation of HIV prevention and social protection of people with HIV. This law has radically changed the system of HIV testing to a voluntary, free and anonymous (if required) service (except for blood donors who are still subject to mandatory testing). The previous legislation provided for compulsory testing of intravenous drug users, patients with STIs, persons identified as “promiscuous”, blood recipients and some other groups. The Law requires treating the results as confidential.

The law also provides for a wide range of prevention activities, including: § an information campaign targeting the general population on the modes of HIV transmission and ways to avoid the infection § ensuring availability of protective means to prevent sexual transmission

57 Ministry of Health of Ukraine, The HIV/AIDS Epidemic in Ukraine: the current situation”, published within the UN Development Programme, Kyiv, 2000, p. 4.

78 § intervention programmes targeting intravenous drug users, including harm reduction strategies of needle exchange § health promotion programmes, promotion of safer sexual practises and the prevention of intravenous drug use

Since 1992, 3 HIV/AIDS prevention programmes have been implemented in Ukraine58.

The importance of the HIV/AIDS problems is highlighted in the presidential Decree “On Urgent Measures on Prevention of HIV/AIDS”, describing the state policy in the field. A governmental commission for HIV/AIDS prevention was established within the Cabinet of Ministers. The commission is headed by the Vice Prime – Minister. However there remains the need for an effective mechanism to implement the Law and presidential decrees in field. At the national level a project on “Strategic Planning of the Measures on Responding to the HIV/AIDS Epidemic in the National Scale for 2001 – 2003” (WHO-UNAIDS) was conducted. The project provided for a situational analysis of the HIV /AIDS epidemic in the country. The project documentation and reports formed the basis for the National Plan for Responding the HIV/AIDS epidemic for 2001-2003 which was developed at the ministerial level. A broad information campaign targeting young people is seen as a priority. The Plan distinguishes between prevention programmes for the general population and interventions targeting high-risk groups. As in previous years, considerable efforts are being made to ensure donor blood safety. The plan provides for large-scale purchase and installation of up to date testing equipment to ensure safety of donor blood. The Plan stipulates a number of medical and social programmes aimed at mitigating the epidemic’s impacts, including centralised purchase of medicines, in particular anti-retrovirals. Soon a decision will be made on Ukraine’s participation in an international project, involving five UN agencies and five big pharmaceutical companies. It would provide scope for reducing the cost of treatment significantly and broaden the access to anti-retroviral therapy.59 The prevention of mother to child transition is a new direction. This work involves the UN-UNICEF Office in Ukraine, Medecins Sans Frontieres and the firms GlaxoSmithKline and Boehringer Ingelheim. A training programme is being developed for gynaecologists and paediatricians.60 Considering that the epidemic began among intravenous drug users, the Programme for Reduction of Harm Caused by Intravenous Drug Use was launched in 1996. The Programme receives support from the UN Office in Ukraine. This programme involves organisations such as Medecins Sans Frontieres, International Renaissance Foundation, UNICEF, youth social service centres, the British Council, Ukrainian Family Planning Association and a number of NGOs. The programme targets intravenous drug users and females sex workers and includes syringe/needle exchange; development and distribution of IEC materials, condoms and disinfectants; medical, psychological and legal counselling; access to medical establishments for IDUs and FSWs. The prevention programmes run by non-governmental and medical organisations have expanded from the oblast centres to other cities with support from oblast and district authorities, health care officials, law enforcement and other state agencies. The National Plan provides for a wide range of prevention programmes targeting young people, including educational campaigns, training workshops, mass media events. A UNAIDS/UNDP programme of peer education involving youth volunteers is being implemented successfully. Evidence all around the world suggest that the shape of HIV/AIDS epidemic is being determined by two key factors: the degree of social cohesion in society and the level of the country’s economic development. Societies with high levels of social cohesion and high standards of living do not seem to experience a rapid

58 UN Development Programme The HIV/AIDS Epidemic in Ukraine: socio-demographic aspect, ?yiv, 2000 - p. 44-50. 59 Source: A.M. Scherbynska AIDS: Problems and Perspectives /‘‘HIV Infection’’ Digest No.9 ?yiv, 2001 p. 18. 60 Source: Same as above, p. 18.

79 HIV/AIDS epidemic. Societies where inequality is not very extreme also seem to avoid serious epidemics. When there is gross inequality and a failing social order, as in Ukraine, then there is a serious possibility that the epidemic will get out of hand and generate very long term social and economic costs. Contemporary Ukrainian society has low levels of wealth and considerable inequality in income and living standards. Considering the deterioration in the demographic situation and the complicated social and economic situation, the epidemic should be responded to urgently. One of the possible (yet not easy) ways to combat the epidemic would be the development of social cohesion, solidarity and a sense of responsibility. This process can be promoted by the development of civil society, or “the third sector”, including professional associations, trade unions, youth and women’s organisations. The role of religious organisations may be important in the western region of Ukraine.

What needs to be done to respond effectively?

· First of all, society must accept the fact that the problem does exist. It is important to understand that the impacts of the epidemic are not purely medical: they will have effects upon many social and economic sectors.

· Secondly, it is necessary to understand the specific aspects of the epidemic.

· Third, there is a need to develop efficient systems of data collection with regard to the epidemic. Also critical is the need for an improved system of sentinel surveillance together with behavioural surveys. A more effective system for case registration and database should be established.

· Fourth, attention needs to be paid to the long term effects of the epidemic and mechanisms to mitigate the epidemic’s effects.

Effective responses would require the involvement of the wide public and careful planning and implementation of specific programmes. As the problem is multi-faceted it should be dealt with on a multi- sectoral basis. There are no “less important” aspects that can be neglected at the cost of another. The response to the epidemic should be multi-pronged and should include the following:

? Development of an appropriate legal basis and a mechanism to ensure that it works ? Development and implementation of an effective prevention programme at the national, oblast, city and township levels ? Effective co-ordination and partnership between the government, non-governmental and private sectors ? Public awareness in order to raise people’s knowledge of HIV related issues ? Building of social capital ? Provision of social support and care to people with HIV ? Involvement and participation of international organisations ? Regular monitoring of the epidemic

To respond effectively to the HIV/AIDS epidemic, society should take the response strategy as a priority. Such a strategy will include:

· effective solutions for HIV/AIDS diagnostics and treatment; · effective prevention strategies at the national level; · political solutions in the fields related to the epidemic.

80 This will require:

1. An inter-sectoral co-ordinating agency at the national level, which would · monitor the epidemic · provide care and treatment for patients with AIDS · organise training for medical workers · carry out information campaigns

2. The state and civil society should join efforts in responding the epidemic, in particular by · implementation of prevention programmes targeting vast masses of population through all means available · information campaigns in order to increase the public’s knowledge of HIV/AIDS and the programmes in the field · organisation of prevention programmes targeting groups at higher risk (FSWs, IDUs, migrant labourers, etc.) · dissemination of information on safer sexual practices and providing means of protection · helping young people to understand the responsibility that sex puts on individuals

3. Prevention at the state level should include: · an effective system for STI treatment; · safe blood transfusion; · programmes for IDUs: needle exchange and other harm reduction strategies; · programmes for FSWs and their clients (harm reduction, helping with rehabilitation, etc.); · launching programmes targeting prisoners, including safer sex and drug use

4. A macro-economic policy that should be oriented at:

·decreasing the gap between the rich and the poor; ·social support to the poorest regions; ·development of the health care sector, in particular provisions for increasing numbers of illnesses and deaths.

5. Planning joint actions of the government, state sector, NGOs, religious organisations in order to mitigate the unavoidable medium and long term effects of the HIV/AIDS epidemic in Ukraine:

· To develop a strategy of support to orphans until they are able to cope with independent living (over 18 years). · To develop adequate policies for support to elderly people. · To support public events and organisations in the field of dealing with the epidemic and its impacts. · To analyse possible impacts of the epidemic at the level of particular sectors, organisations and industries (both public and private) and develop an adequate response strategy.

81 Appendix 1

CORRELATION BETWEEN LEVEL OF REGIONAL DEVELOPMENT AND THE HIV SITUATION REGRESSION ANALYSIS

Table 1. Integral indexes of human development and regional human development (data from 1999) + HIV rate (cases per 100, 000 population)

Integral index Number of people Regional Demogr Labo Ed Financ with HIV Inc Living Social Ecologic human Regions aphic ur Health uca ial per 100 om conditio environ al developme develop mark care tio situati thousand e ns ? ment situation nt ment et n on populatio n Crimea 0,369 0,508 0,448 0,462 0,567 0,388 0,482 0,319 0,877 0,470 13,31 Autonomous Republic Vinnitsa 0,563 0,651 0,381 0,19 0,802 0,344 0,653 0,336 0,616 0,474 2,55 Volyn’ 0,521 0,519 0,369 0,249 0,604 0,243 0,705 0,317 0,741 0,443 1,14 Dnipropetrovs 0,368 0,565 0,508 0,401 0,554 0,451 0,392 0,317 0,395 0,441 33,18 k Donetsk 0,301 0,608 0,534 0,278 0,57 0,458 0,479 0,303 0,311 1,430 27,61 Zhytomyr 0,457 0,565 0,329 0,228 0,637 0,33 0,571 0,326 0,774 0,436 4,07 Zakarpattiya 0,501 0,686 0,275 0,228 0,773 0,277 0,767 0,312 0,824 0,471 1,57 Zaporizhzya 0,381 0,519 0,518 0,427 0,541 0,367 0,415 0,334 0,567 0,446 7,01 Ivano 0,634 0,552 0,399 0,167 0,706 0,298 0,768 0,338 0,612 0,468 1,59 Frankovsk Kyiv 0,391 0,687 0,481 0,328 0,592 0,402 0,555 0,318 0,69 0,476 3,95 Kirovograd 0,329 0,617 0,419 0,191 0,544 0,36 0,436 0,308 0,82 0,419 2,77 Lugansk 0,357 0,485 0,366 0,217 0,606 0,258 0,346 0,329 0,705 0,381 4,82 Lviv 0,542 0,588 0,408 0,303 0,63 0,412 0,782 0,318 0,678 0,495 2,26 Mykolaiv 0,381 0,529 0,42 0,319 0,412 0,301 0,425 0,326 0,898 0,419 27,23 Odesa 0,347 0,606 0,436 0,308 0,411 0,426 0,497 0,318 0,774 0,440 38,64 Poltava 0,616 0,578 0,482 0,281 0,697 0,421 0,547 0,307 0,596 0,486 11,12 Rivne 0,517 0,593 0,387 0,219 0,601 0,319 0,777 0,338 0,911 0,480 ,42 Sumy 0,382 0,46 0,423 0,188 0,636 0,342 0,514 0,317 0,804 0,424 4,05 Ternopil 0,629 0,656 0,311 0,278 0,624 0,341 0,819 0,341 0,907 0,503 1,39 Kharkiv 0,425 0,516 0,498 0,371 0,281 0,584 0,492 0,314 0,719 0,462 3,93 Kherson 0,264 0,649 0,451 0,327 0,582 0,327 0,462 0,339 0,795 0,442 5,89 Khmelnytsk 0,563 0,56 0,317 0,257 0,734 0,408 0,656 0,357 0,892 0,488 11,89 Cherkassy 0,575 0,477 0,407 0,25 0,747 0,429 0,573 0,334 0,851 0,484 8,16 Chernivtsi 0,669 0,31 0,198 0,164 0,782 0,255 0,755 0,414 0,885 0,443 2,99 Chernigiv 0,488 0,537 0,465 0,226 0,399 0,362 0,577 0,319 0,774 0,440 2,81 Kyiv City 0,848 0,823 0,803 0,911 0,635 0,824 0,648 0,317 0,858 0,747 4,77 Sevastopil 0,18 0,508 0,488 0,503 0,571 0,525 0,504 0,671 0,831 0,518 18,24 City

82 Table 2. List of indicators constituting the integral; indexes most correlative to the HIV rate

Index Indicators

1. Social environment Crime situation, percentage of grave crimes; suicide rate per 100,000 population; number of cases of tuberculoses in active form per 100,000 population, registered number of patients diagnosed for alcoholism and psycho diseases caused by addictions per 100,000 population; % of unemployed during a year or longer; correlation of marriage and divorce rates; percentage of children born out of marriage; number of car accidents per 100 km. of the road network; delayed wages and pensions (in UAH) per employed or pensioner.

2. Demographic development Infant mortality; perinatal mortality; migration balance; ratio of migration intensity; life expectancy of the general population at the age of 15, 45 and 65. 3. Health care Number of accidents at work; % of children under 2 years reached by immunisation for diphtheria, whooping-cough, poliomyelitis, measles, and, tuberculoses; conventional health ratio; number of physicians of all specialities per 10,000 population, number of first aid clinics per 100,000 population . 4. Ecological situation Quantity of toxic waste products stored; heavy metals in sewage (per 1 thousand sq. km.); leak of sulphur, nitrogen, lead other harmful substances (kg. per 1 person)

Table 3. Regression model

In this model the R indicator was equal 0.630. This is the ratio of correlation between our variables. R square shows the portion of HIV rate that can be explained by independent variables. In our case, 39.6% of the HIV rate is caused by the selected factors. Coefficients Unstandardized Standardised t Sig. Collinearity Coefficients Coefficients Statistics Model B Std. Error Beta Tolerance VIF 1 (Constant) 71,400 24,425 2,923 ,008 -55,162 38,306 -,567 -1,440 ,165 ,185 5,402 Well being Living conditions 39,363 25,008 ,557 1,574 ,130 ,229 4,359 Health condition and -21,612 18,149 -,252 -1,191 ,247 ,644 1,553 the situation with health care Social environment -29,168 16,367 -,379 -1,782 ,089 ,636 1,573 Ecological situation -28,085 15,255 -,402 -1,841 ,080 ,603 1,659

Dependent Variable: HIV (HIV infected per 100,000 population) Among the selected variables, social environment was of the biggest use: its regression ratio was equal to –29,16. The least useful ones were material well-being and health care (lower than other statistic data). ? coefficient – regression coefficients used to build a projection model for HIV development based on the selected factors. Tolerance, VIF are in reverse ratio: the lower tolerance the higher likelihood of dispersion. Regression coefficient for dispersion grows with VIF.

83 Appendix 2

OUTPUT DATA FROM PROJECTION IN THE “SPECTRUM” PROGRAMME

Year the HIV/AIDS epidemic started: 1994 The final year of projection: 2010

DEMOGRAPHIC SITUATION IN UKRAINE

WITHOUT HIV/AIDS WITH AIDS Optimistic scenario Pessimistic scenario 2002 2005 2010 2002 2005 2010 2002 2005 2010 Fertility Input TFR 1,11 1,13 1,23 1,11 1,13 1,23 1,11 1,13 1,23 Calculated TFR 1,11 1,13 1,23 1,10 1,12 1,21 1,10 1,10 1,17 GRR 0,54 0,55 0,60 0,54 0,54 0,59 0,53 0,54 0,57 NRR 0,53 0,54 0,59 0,52 0,53 0,58 0,52 0,52 0,56 Mean Age of Childbearing 25,1 25,3 25,5 27,2 27,2 27,2 27,2 27,2 27,2 Child-woman ratio 0,15 0,16 0,18 0,15 0,15 0,17 0,15 0,15 0,17 Mortality Male LE 62,4 63,2 64,2 61,5 61,6 62,2 61,5 61,2 60,1 Female LE 73,4 73,8 74,4 72,7 72,5 72,1 72,7 72,1 69,7 Total LE 68,3 68,8 69,6 67,5 67,4 67,6 67,5 67,0 65,3 IMR 13,0 12,3 11,4 13,1 12,3 11,4 13,1 12,4 11,4 U5MR 17,0 16,0 14,6 17,2 16,0 14,7 17,2 16,1 14,9 Immigration (Thousands) Male immigration -18,90 -17,60 -13,60 -18,90 -17,60 -13,60 -18,90 -17,60 -13,60 Female immigration -25,00 -22,40 -16,40 -25,00 -22,40 -16,40 -25,00 -22,40 -16,40 Total immigration -43,90 -40,00 -30,00 -43,90 -40,00 -30,00 -43,90 -40,00 -30,00 Vital Rates CBR per 1000 8,1 8,5 9,5 8,0 8,4 9,4 8,0 8,3 9,1 CDR per 1000 15,7 16,0 16,2 16,1 16,6 17,3 16,1 16,8 18,3 RNI percent -0,76 -0,74 -0,68 -0,81 -0,83 -0,79 -0,81 -0,85 -0,92 GR percent -0,85 -0,83 -0,74 -0,90 -0,91 -0,85 -0,90 -0,93 -0,98 Annual births and deaths (Thousands) Births 393,70 403,58 430,49 386,20 393,90 422,80 385,50 390,10 410,70 Deaths 762,18 755,24 738,04 777,31 783,87 778,10 777,31 790,40 822,80 Population (Millions) Total population 48,49 47,28 45,48 48,43 47,12 45,09 48,43 47,10 44,89 Male population 22,49 21,92 21,08 22,45 21,82 20,86 22,45 21,81 20,75 Female population 25,99 25,36 24,40 25,97 25,30 24,23 25,97 25,29 24,14 Percent 0-4 4,04 4,15 4,61 3,99 4,07 4,54 3,99 4,06 4,47 Percent 5-14 12,30 10,40 8,79 12,33 10,42 8,75 12,33 10,42 8,77 Percent 15-49 51,86 52,50 51,86 51,86 52,51 51,89 51,87 52,52 51,89 Percent 15-64 68,57 69,65 70,82 68,58 69,67 70,83 68,58 69,67 70,83 Percent 65 and over 15,09 15,80 15,79 15,10 15,84 15,87 15,10 15,85 15,93 Percent females 15-49 48,97 49,47 48,70 48,98 49,48 48,71 48,98 49,49 48,70 Sex ratio 86,52 86,43 86,39 86,46 86,27 86,08 86,46 86,25 85,95 Dependency ratio 0,46 0,44 0,41 0,46 0,44 0,41 0,46 0,44 0,41 Median age 38 39 39 38 39 39 38 39 39

84 HIV/AIDS EPIDEMIC IN UKRAINE: EPIDEMIOLOGICAL INDICATORS:

OPTIMISTIC SCENARIO PESSIMISTIC SCENARIO 2001 2002 2005 2010 2001 2002 2005 2010 HIV population, mln. Total 0,336 0,367 0,458 0,582 0,41 0,53 0,90 1,44 Males 0,208 0,221 0,255 0,289 0,25 0,32 0,50 0,72 Females 0,128 0,147 0,203 0,293 0,16 0,21 0,40 0,72 Adult prevalence, % 1,08 1,18 1,47 1,97 1,33 1,73 2,92 4,91 New AIDS cases, ths. Total 13,16 17,86 31,69 44,36 13,16 17,86 40,61 95,21 Males 9,04 11,85 19,44 23,57 9,04 11,85 24,68 50,92 Females 4,12 6,01 12,26 20,79 4,12 6,01 15,93 44,29 Annual HIV+ births Total cases 84 68 69 110 104 100 136 273 Percent 0,02 0,02 0,02 0,03 0,03 0,03 0,03 0,07 Annual AIDS deaths (ths.) Total 10,80 15,51 29,77 43,40 10,80 15,51 36,31 89,20 Males 7,42 10,45 18,45 23,37 7,42 10,45 22,30 48,20 Females 3,38 5,06 11,32 20,03 3,38 5,06 14,01 41,00 Per thousand 0,22 0,32 0,63 0,96 0,22 0,32 0,77 1,99 Cumulative AIDS deaths (ths.) Total 23,66 39,17 114,28 307,81 23,66 39,17 125,14 459,39 Males 16,59 27,03 74,69 184,44 16,59 27,03 81,15 269,19 Females 7,08 12,14 39,59 123,37 7,08 12,14 43,99 190,20 %of the budgt of the Health Minsitry 9,4 11,4 16,9 22,6 9,4 11,4 21,7 48,5 required to respond the AIDS epidemic Projected clinic attendancy 0,47 0,64 1,14 1,60 0,47 0,64 1,46 3,43 (days per bed) (mln.) % of beds required 0,4 0,5 0,9 1,3 0,4 0,5 1,1 2,7 AIDS mortality among 112 94 46 64 112 99 73 148 children (number of deaths) Children who will loose parents because of AIDS (ths.) Total 5,17 8,12 20,53 46,37 5,17 8,12 23,55 77,36 Men 2,64 4,15 10,51 23,73 2,64 4,15 12,06 39,59 Women 2,53 3,97 10,02 22,64 2,53 3,97 11,50 37,78

85 HIV/AIDS EPIDEMIC IN THE GENDER AND AGE CONTEXT: OPTIMISTIC SCENARIO

Number of infected (thousands of persons)

2005 2100 Age T Men Women Age To Men Women o tal ta l 0-4 0,26 0,13 0,13 0-4 0,26 0,13 0,13 5-9 0,15 0,08 0,07 5-9 0,15 0,08 0,07 10-14 0,00 0,00 0,00 10-14 0,00 0,00 0,00 15-19 19,12 6,98 12,14 15-19 19,12 6,98 12,14 20-24 41,25 10,65 30,60 20-24 41,25 10,65 30,60 25-29 62,95 32,84 30,11 25-29 62,95 32,84 30,11 30-34 77,91 49,18 28,73 30-34 77,91 49,18 28,73 35-39 60,85 41,39 19,46 35-39 60,85 41,39 19,46 40-44 52,15 32,93 19,23 40-44 52,15 32,93 19,23 45-49 50,75 28,21 22,54 45-49 50,75 28,21 22,54 50-54 45,13 26,13 19,00 50-54 45,13 26,13 19,00 55-59 20,03 12,60 7,42 55-59 20,03 12,60 7,42 60-64 14,36 7,30 7,06 60-64 14,36 7,30 7,06 65-69 10,35 4,62 5,72 65-69 10,35 4,62 5,72 70-74 2,36 1,28 1,08 70-74 2,36 1,28 1,08 75-79 0,38 0,27 0,11 75-79 0,38 0,27 0,11 80+ 0,00 0,00 0,00 80+ 0,00 0,00 0,00 ?????? 458,00 254,60 203,40 ?????? 458,00 254,60 203,40

Number of new AIDS cases (thousands of persons)

2005 2100 Age T Men Women Age To Men Women o tal ta l 0-4 0,05 0,02 0,02 0-4 0,06 0,03 0,03 5-9 0,04 0,02 0,02 5-9 0,02 0,01 0,01 10-14 0,00 0,00 0,00 10-14 0,00 0,00 0,00 15-19 0,22 0,08 0,14 15-19 0,26 0,09 0,17 20-24 1,64 0,63 1,01 20-24 2,50 0,81 1,70 25-29 2,96 1,07 1,90 25-29 4,78 1,40 3,38 30-34 4,66 2,89 1,76 30-34 6,76 3,67 3,08 35-39 5,18 3,54 1,64 35-39 7,61 4,77 2,83 40-44 4,83 3,51 1,33 40-44 5,50 3,67 1,83 45-49 3,75 2,50 1,25 45-49 4,75 2,76 1,99 50-54 3,46 2,12 1,34 50-54 4,71 2,45 2,26 55-59 2,13 1,36 0,77 55-59 3,86 2,15 1,72 60-64 1,27 0,83 0,43 60-64 1,56 0,92 0,64 65-69 1,07 0,59 0,48 65-69 1,13 0,50 0,63 70-74 0,37 0,21 0,16 70-74 0,71 0,28 0,44 75-79 0,07 0,05 0,02 75-79 0,13 0,06 0,06 80+ 0,00 0,00 0,00 80+ 0,02 0,01 0,00 Total 31,69 19,44 12,26 Total 44,36 23,57 20,79

86 HIV/AIDS EPIDEMIC IN THE GENDER AND AGE CONTEXT: PESSIMISTIC SCENARIO Number of infected (millions of persons)

2005 2100 Age T Men Women Age T Men Women o o ta ta l l 0-4 0,00 0,00 0,00 0-4 0,00 0,00 0,00 5-9 0,00 0,00 0,00 5-9 0,00 0,00 0,00 10-14 0,00 0,00 0,00 10-14 0,00 0,00 0,00 15-19 0,04 0,01 0,02 15-19 0,05 0,02 0,03 20-24 0,08 0,02 0,06 20-24 0,14 0,03 0,11 25-29 0,12 0,07 0,06 25-29 0,21 0,10 0,11 30-34 0,15 0,10 0,06 30-34 0,25 0,14 0,11 35-39 0,12 0,08 0,04 35-39 0,20 0,13 0,07 40-44 0,10 0,07 0,04 40-44 0,14 0,08 0,06 45-49 0,10 0,06 0,04 45-49 0,16 0,08 0,08 50-54 0,09 0,05 0,04 50-54 0,14 0,07 0,07 55-59 0,04 0,02 0,01 55-59 0,08 0,04 0,03 60-64 0,03 0,01 0,01 60-64 0,04 0,02 0,02 65-69 0,02 0,01 0,01 65-69 0,03 0,01 0,02 70-74 0,00 0,00 0,00 70-74 0,01 0,00 0,00 75-79 0,00 0,00 0,00 75-79 0,00 0,00 0,00 80+ 0,00 0,00 0,00 80+ 0,00 0,00 0,00 Total 0,90 0,50 0,40 Total 1,44 0,72 0,72

Number of new AIDS cases (thousands of persons)

2005 2100 Age T Men Women Age To Men Women o tal ta l 0-4 0,07 0,04 0,04 0-4 0,15 0,08 0,07 5-9 0,04 0,02 0,02 5-9 0,03 0,01 0,01 10-14 0,00 0,00 0,00 10-14 0,00 0,00 0,00 15-19 0,39 0,15 0,24 15-19 0,62 0,20 0,42 20-24 2,22 0,82 1,40 20-24 5,35 1,70 3,65 25-29 3,97 1,50 2,47 25-29 10,16 3,03 7,14 30-34 6,06 3,75 2,31 30-34 14,38 7,82 6,56 35-39 6,62 4,52 2,10 35-39 16,19 10,10 6,09 40-44 6,06 4,35 1,71 40-44 11,95 7,95 4,01 45-49 4,80 3,15 1,64 45-49 10,53 6,19 4,34 50-54 4,38 2,66 1,72 50-54 10,33 5,47 4,86 55-59 2,68 1,70 0,98 55-59 8,30 4,65 3,65 60-64 1,57 1,02 0,55 60-64 3,29 1,92 1,36 65-69 1,28 0,71 0,57 65-69 2,53 1,15 1,38 70-74 0,39 0,23 0,16 70-74 1,23 0,54 0,69 75-79 0,07 0,05 0,02 75-79 0,16 0,10 0,06 80+ 0,00 0,00 0,00 80+ 0,02 0,01 0,01 Total 40,61 24,68 15,93 Total 95,21 50,92 44,29

87 nnex 3 HIV/AIDS data

Table 1. HIV among donors by region (data provided by the Ukrainian AIDS Centre: current statistics )

Region 1998 1999 2000 Tested Positive % Tested Positive % Tested Positive % Crimea Republic 75,621 72 0.095 72, 202 60 0.083 73 217 59 0.081 Vinnitsa 53, 216 20 0.038 50, 992 16 0.031 50 650 12 0.024 Volyn 32 ,911 7 0.021 28, 381 10 0.035 29 971 9 0.030 Dniepropetrovsk 93, 300 81 0.087 92, 409 140 0.152 86 071 122 0.142 Donetsk 92, 415 72 0.078 81, 387 62 0.076 71 369 50 0.070 Zhytomyr 28, 598 4 0.014 26, 053 0 0.000 26 923 7 0.026 Zakarpati’ya 30, 517 0 0.000 24, 009 3 0,012 22 063 5 0.023 Zaporizhzhya 59, 694 14 0.023 57, 613 12 0.021 54 773 14 0.026 Ivano-frankivsk 20, 762 1 0.005 17, 917 2 0,011 17 477 2 0.011 Kyiv 30, 494 117 0.384 31, 032 65 0.209 34 474 65 0.189 Kirovograd 20, 853 4 0.019 15, 639 7 0,045 15 025 14 0.093 Lugansk 78, 695 24 0.030 61, 306 18 0.029 65 003 16 0.025 Lviv 37, 459 5 0.013 32, 025 7 0.022 30 726 8 0.026 Mykolaiv 19, 576 55 0.281 17, 244 29 0.168 17 571 56 0.319 Odesa 48, 615 142 0.292 46, 408 100 0.215 44 096 103 0.234 Poltava 36, 059 14 0.039 33, 171 10 0.030 28 956 14 0.048 Rivne 28, 069 2 0.007 18, 487 2 0,011 16 116 0 0.000 Sumy 27, 485 2 0.007 25 509 2 0.008 23 900 0 0,000 Ternopil 22, 223 2 0.009 15, 325 1 0.007 16 221 3 0.018 Kharkiv 78, 029 4 0.005 62, 888 6 0.010 56 118 17 0.030 Kherson 23, 447 6 0.026 19, 244 16 0.083 21 689 9 0.041 Khmelnytsk 49, 141 13 0.026 46, 904 20 0.043 46 650 34 0.073 Cherkassy 30, 571 35 0.114 26, 108 19 0.073 25 113 38 0.151 Chernivtsi 16, 248 4 0.025 16, 043 0 0.000 18 277 2 0.011 Chernigiv 27, 617 12 0.043 24, 607 13 0.053 23 772 18 0.076 Kyiv City 69, 410 41 0.059 63, 401 29 0.046 58 470 47 0,080 Sevastopil City 16, 553 8 0.048 15, 516 4 0.026 14 853 3 0.020 Total: 1, 147, 578 761 0.066 1, 021, 820 653 0.064 989 544 727 0.073

88 Table 2. Number of persons officially registered as «drug addicted» in Ukraine*

HIV infected IDUs Regions Number of persons on 1994 – 1998** 1999 1994-1999 2000 2001 1994-2001 01.01.2001 Crimea Republic 3,891 1,079 184 1, 263 211 255 1,729 Vinnitsa 873 130 34 164 80 90 334 Volyn 1,297 222 11 233 83 51 367 Dniepropetrovsk 15,522 4,503 864 5,367 612 474 6,453 Donetsk 9,173 4,143 862 5,005 867 831 6,703 Zhytomyr 1,194 177 42 219 38 105 362 Zakarpati’ya 234 43 5 48 8 9 65 Zaporizhzhya 4,803 656 89 745 95 107 947 Ivano-frankivsk 774 46 19 65 11 15 91 Kyiv oblast 1,303 143 59 202 47 139 388 Kirovograd 1,566 45 17 62 28 55 145 Lugansk 2,618 500 82 582 100 126 808 Lviv 811 129 54 183 72 86 341 Mykolaiv 4,160 1,389 265 1,654 316 263 2,233 Odesa 7,822 2,617 462 3,079 492 381 3,952 Poltava 2,159 480 148 628 88 93 809 Rivne 836 43 4 47 20 19 86 Sumy 805 68 40 108 28 58 194 Ternopil 319 78 14 92 53 33 178 Kharkiv 1,659 527 67 594 84 83 761 Kherson 1,928 277 36 313 45 66 424 Khmelnytsk 1,777 210 113 323 64 84 471 Cherkassy 1,632 508 89 597 96 120 813 Chernivtsi 500 168 20 188 17 8 213 Chernigiv 1,749 175 28 203 75 103 381 Kyiv City 5,710 724 107 831 172 231 1,234 Sevastopil City 374 268 56 324 79 79 482 Total: 75,489 19,348 3,771 23,119 3,881 3,964 30,964 * Data provided by the Ukrainian AIDS Centre ** Until 1994, there was no registration of HIV positive IDUs.

Table 3. Syphilis and gonorrhoea prevalence in Ukraine in 1998-2000*

89 Syphilis Gonorrhoea Region Number of persons Per 100,000 Number of persons Per 100,000 population population 1998 1999 2000 1998 1999 2000 1998 1999 2000 1998 1999 2000 Crimea Republic 3,058 2,491 2,095 143.6 117 100.3 1,340 1,237 1,330 62.9 58.1 63.7 Vinnitsa 2,029 1,539 1,332 110.6 83.8 73.9 447 431 430 24.4 23.5 23.8 Volyn 1,104 968 1,111 103.6 90.9 105.2 396 406 448 37.2 38.1 45.8 Dniepropetrovsk 8,904 6,741 4,886 236.6 179 132 4,162 3,273 3,082 87 87 83.3 Donetsk 9,866 7,573 5,354 195.6 150.1 108.5 2,052 2,135 2,113 40.7 42.3 42.8 Zhytomyr 1,513 1,330 1,163 104.4 91.8 81.6 429 413 438 29.6 28.5 30.7 Zakarpati’ya 1,154 969 769 90 75.6 60.2 821 600 553 64.1 46.8 43.3 Zaporizhzhya 4,279 3,314 2,300 210.3 162.9 115.2 1,117 993 892 54.9 48.8 44.7 Ivano-frankivsk 1,259 915 910 86.6 63 62.9 622 584 599 42.8 40.2 41.4 Kyiv 2,022 1,756 1,493 108.8 94.5 81.8 547 724 589 29.4 39 32.3 Kirovograd 1,586 1,138 1,038 133.7 95.9 89.7 512 497 560 43.2 41.9 48.4 Lugansk 4,966 3,852 3,260 183.9 142.6 123.6 1,997 1,611 1,750 73.9 59.6 66.4 Lviv 1,610 1,406 1,220 59.2 51.7 45.2 871 746 713 32 27.4 26.4 Mykolaiv 3,269 2,552 1,815 247.6 193.3 140 920 876 903 69.7 66.4 69.6 Odesa 3,761 3,512 2,687 148.7 138.8 107.8 1,116 1,052 1,063 44.1 41.6 42.7 Poltava 2,466 2,271 2,030 144.7 133.3 121.3 1,147 1,216 1,339 67.3 71.4 80 Rivne 1,087 941 899 91.6 79.3 76 529 602 551 44.6 50.7 46.6 Sumy 1,515 1,204 907 111 88.2 68.1 1,454 1,636 1,382 106.5 119.9 103.7 Ternopil 7,44 610 591 63.9 52.4 51.3 669 627 813 57.5 53.9 70.5 Kharkiv 2,223 1,797 1,548 74 59.8 52.5 1,534 1,451 1,330 51.1 48.3 45.1 Kherson 2,541 2,437 1,391 204.3 195.9 113.7 695 760 653 55.9 61.1 53.4 Khmelnytsk 1,449 1,135 1039 97.9 76.6 71.7 1,698 1,386 1,678 114.7 93.6 115.3 Cherkassy 1,376 1,431 1,110 93.3 97 76.7 643 684 668 43.6 46.4 46.2 Chernivtsi 1,031 1,072 950 109.5 113.9 101.6 605 601 575 64.3 63.8 61.5 Chernigiv 1,094 956 878 83.2 72.7 68.9 288 288 341 21.9 21.9 26.6 Kyiv City 2,955 2,242 1,922 113.7 86.3 73.9 1,049 1,006 1,029 40.4 38.7 39.6 Sevastopil City 662 647 547 166.7 162.8 140.4 287 267 199 69.9 67.2 51.1 Total: 69,523 56,799 45,245 138.4 113.1 51.5 27,938 26,102 26,057 55.6 51.9 52.7 *Source: the Centre of Medical Statistics, Health Ministry of Ukraine.

90 Table 4. HIV prevalence among patients with STIs (data provided by the Ukrainian AIDS Centre)

Regions 1998 ?. 1999 2000 Tested Posit % Tested Positiv % Tested Posit % ive e ive Crimea Republic 22,191 94 0.424 13 ,805 57 0.413 11,320 66 0,58 Vinnitsa 1, 777 0 0000 757 1 0.132 921 3 0,33 Volyn 4, 016 4 0.100 5, 091 2 0.039 4,175 6 0,14 Dniepropetrovsk 16, 345 58 0355 8, 524 92 1.079 7,518 77 1,02 Donetsk 26, 334 296 1.124 16, 130 159 0.986 12,985 141 1,06 Zhytomyr 5, 555 20 0.360 5, 788 43 0.743 3,833 25 0,65 Zakarpati’ya 3, 983 5 0.126 2, 534 3 0.118 2,325 1 0,04 Zaporizhzhya 11, 021 16 0.145 9, 843 14 0.142 8,186 22 0,27 Ivano-frankivsk 2, 415 0 0.000 1, 779 1 0056 1,461 3 0,21 Kyiv 1, 563 9 0.576 1, 610 16 0.994 1,822 18 0,99 Kirovograd 3,961 12 0.303 142 1 0.704 214 5 2,34 Lugansk 12, 766 21 0.164 8, 144 13 0.160 9,645 15 0,16 Lviv 2, 451 1 0.041 817 1 0.122 5,099 14 0,27 Mykolaiv 2,160 96 4.444 180 7 3.889 994 37 3,72 Odesa 26, 135 304 1.163 21, 670 324 1.495 18,850 295 1,56 Poltava 9, 413 43 0.457 5, 272 23 0.436 1,543 4 0,26 Rivne 6, 566 2 0.030 427 0 0.000 125 - - Sumy 4, 219 3 0.071 2, 215 9 0.406 1,344 2 0,15 Ternopil 1, 317 0 0.000 734 1 0.136 588 3 0,51 Kharkiv 8, 738 18 0.206 6, 233 8 0.128 4,796 14 0,29 Kherson 3, 363 8 0.238 2, 014 5 0.248 3,031 17 0,56 Khmelnytsk 9, 405 25 0.266 8, 881 13 0.146 4,560 7 0,15 Cherkassy 9, 282 30 0.323 4, 819 14 0.291 5,360 24 0,45 Chernivtsi 6, 658 2 0.030 1, 140 3 0.263 941 2 0,21 Chernigiv 415 1 0.241 302 1 0.331 771 2 0,26 Kyiv City 1, 621 6 0.370 1, 440 13 0.903 1,444 12 0,83 Sevastopil City 2, 661 9 0.338 1, 027 2 0.195 992 2 0,20 Total: 206, 331 1, 083 0.525 131, 318 826 0.629 114,843 817 0,71

95 Table 5. Recorded AIDS cases by region (data provided by the Ukrainian AIDS Centre)

1987 – 2000 2001 1987 – 2001 Regions Foreign Ukrainian Total Foreign Ukrainian Total Foreign Ukrainian Total nationals nationals nationals nationals nationals nationals Crimea Republic 0 247 247 0 80 80 0 327 327 Vinnitsa 2 12 14 0 10 10 2 22 24 Volyn 0 3 3 0 2 2 0 5 5 Dniepropetrovsk 1 99 100 0 24 24 1 123 124 Donetsk 0 137 137 0 212 212 0 349 349 Zhytomyr 0 19 19 0 19 19 0 38 38 Zakarpati’ya 0 8 8 0 2 2 0 10 10 Zaporizhzhya 0 26 26 0 35 35 0 61 61 Ivano-frankivsk 1 9 10 1 4 5 2 13 15 Kyiv 0 7 7 0 18 18 0 25 25 Kirovograd 0 2 2 0 5 5 0 7 7 Lugansk 0 8 8 0 12 12 0 20 20 Lviv 0 17 17 0 10 10 0 27 27 Mykolaiv 0 319 319 0 34 34 0 353 353 Odesa 2 900 902 1 288 289 3 1,188 1,192 Poltava 0 2 2 0 0 0 0 2 2 Rivne 0 5 5 0 0 0 0 5 5 Sumy 0 10 10 0 25 25 0 35 35 Ternopil 0 11 11 0 2 2 0 13 13 Kharkiv 0 17 17 0 7 7 0 24 24 Kherson 0 89 89 0 5 5 0 94 94 Khmelnytsk 0 2 2 0 0 0 0 2 2 Cherkassy 0 9 9 0 7 7 0 16 16 Chernivtsi 0 21 21 0 1 1 0 22 22 Chernigiv 0 6 6 0 3 3 0 9 9 Kyiv City 8 49 57 0 43 43 8 92 100 Sevastopil City 0 6 6 0 19 19 0 25 25 Total: 14 2040 2054 2 867 869 16 2,907 2,923

96 Table 6. AIDS mortality by region (data provided by the Ukrainian AIDS Centre)

Regions 1987 – 2000 2001 1987 - 2001 Foreign Ukrainian Total Foreign Ukrainian Total Foreig Ukrainian Total citizens nationals nationals nationals n nationals nationa ls Crimea Republic 0 88 88 0 45 45 0 133 133 Vinnitsa 1 2 3 0 5 5 1 7 8 Volyn 0 3 3 0 2 2 0 5 5 Dniepropetrovsk 1 53 54 0 14 14 1 67 68 Donetsk 0 77 77 0 111 111 0 188 188 Zhytomyr 0 13 13 0 13 13 0 26 26 Zakarpati’ya 0 4 4 0 0 0 0 4 4 Zaporizhzhya 0 20 20 0 18 18 0 38 38 Ivano-frankivsk 1 3 4 1 3 4 2 6 8 Kyiv 0 3 3 0 6 6 0 9 9 Kirovograd 0 1 1 0 0 0 0 1 1 Lugansk 0 2 2 0 1 1 0 3 3 Lviv 0 8 8 0 4 4 0 12 12 Mykolaiv 0 226 226 0 17 17 0 243 243 Odesa 2 429 431 0 196 196 2 625 627 Poltava 0 0 0 0 0 0 0 0 0 Rivne 0 2 2 0 0 0 0 2 2 Sumy 0 3 3 0 8 8 0 11 11 Ternopil 0 4 4 0 0 0 0 4 4 Kharkiv 0 10 10 0 5 5 0 15 15 Kherson 0 7 7 0 1 1 0 8 8 Khmelnytsk 0 1 1 0 0 0 0 1 1 Cherkassy 0 6 6 0 3 3 0 9 9 Chernivtsi 0 13 13 0 1 1 0 14 14 Chernigiv 0 4 4 0 1 1 0 5 5 Kyiv City 6 14 20 0 6 6 6 20 26 Sevastopil City 0 4 4 0 13 13 0 17 17 Total: 11 1, 000 1, 011 1 473 474 12 1,473 1,485

97