Azerbaijan, Armenia with low HIV prevalence: what statistics say?
Armenia are Azerbaijan are the countries with low HIV prevalence (<0.3%), according to statistics. Yet the dramatic, almost nine fold increases in registered HIV cases in the region between 2000 and 2008 (from 574 to 5323) remain a cause for serious concern.
This report summarizes and compares the latest data on the epidemiology of HIV/AIDS in Southern Caucasus nations of Armenia, Azerbaijan. It also provides a comparison with HIV/AIDS situation in Eastern Europe. The work is mainly based on the review of UNAIDS country progress reports and end-year reports of HIV/AIDS Surveillance in Europe.
Trends in HIV/AIDS spread in Southern Caucasus are similar to trends in Eastern Europe: the number of HIV and AIDS cases continues to increase. The vast majority of people living with HIV/AIDS were aged 25-49-years at the time of diagnosis.
The official information confirms that the epidemic in Southern Caucasus remains located among males (with 83.8% in Azerbaijan and 73% in Armenia) and most-at-risk populations. In Azerbaijan, as in Eastern Europe, the predominant mode of transmission is through injecting drug use (64.2%), while in Armenia over the last several years the transmission has shifted from injecting drug use to heterosexual spread (50.2%).
The second reported mode of transmission in Azerbaijan is unprotected heterosexual activity (23.4%). Medical transmission, mother to child transmission, and transmission among men who have sex with men are rare, typically comprising less than 3% of total registered transmission in each country of the region.
As UNAIDS contends the prevalence values are underestimated, and the registered numbers of HIV/AIDS cases in the region do not reflect the actual spread of the infection. There is also a substantial discrepancy between the cumulative number of HIV/AIDS cases reported in the national case reporting systems and the HIV prevalence reported in surveys (high prevalence observed in IDUs in Armenia and Azerbaijan). In the context of such underreporting, population-based and community-based HIV surveys have far better public health utility in estimating burden of HIV/AIDS than the case reporting system.
What is HIV?
HIV is a virus spread through certain body fluids that attacks the body’s immune system, specifically the CD4 cells, often called T cells. Over time, HIV can destroy so many of these cells that the body can’t fight off infections and disease. These special cells help the immune system fight off infections.
Untreated, HIV reduces the number of CD4 cells (T cells) in the body. This damage to the immune system makes it harder and harder for the body to fight off infections and some other diseases. Opportunistic infections or cancers take advantage of a very weak immune system and signal that the person has AIDS.
Azerbaijan has a population of around 10m and 22.7% of the population is under the age of 15 years, and 6.3% of the population is above the age of 65 years. 53.6% of the population resides in urban areas. Administratively, the country is divided into 66 districts and 11 cities.
Epidemic analysis: latest trends
The incidence of newly diagnosed HIV infections in 2013 was 5.6 per 100,000 people. HIV sero-prevalence in key populations was 9.5% among people who inject drugs (PWID), 5.8% in prisoners, 2.0% among men who have sex with men (MSM), and 0.7% among female sex workers (FSW).
Recent trends in the epidemiology of HIV in Azerbaijan suggest that the incidence of HIV is increasing among those infected through heterosexual transmission, particularly among young women: the proportion of female HIV cases rose from 17% in 2010 to 22% in 2013. As in most countries in the region, this heterosexual transmission is most likely to be from men at high risk (such as PWID and MSM) to their female sexual partners. Of Azerbaijani citizens with HIV, 558 (21.3%) were infected with HIV abroad, predominantly in Russia.
HIV prevalence in the country differs from district to district and is notably higher in Sirvan, Haciqabul, Astara, Lankaran districts and Sumgayit city. The number of cumulative HIV cases from 1987 to 2013 was 4,298, of whom 4,149 (96.5%) were Azerbaijani citizens; 3,353 (78%) were male and 945 (22%) female. The estimated sizes of key populations include people living with HIV (PLHIV): 9,159, PWID: 71,283, FSW: 25, 054, MSM: 6,572 and prisoners: 17, 000.
As cited in the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM) Project Implementation Unit May 2014, Semi-Annual Progress Report, injecting drug use continues to be the primary mode of HIV transmission.
According to the 2014 press release from the AIDS Center, out of 4,149 Azerbaijani citizens with HIV, 2,400 (57.8%) were infected through injecting drugs; 1,310 (31.6%) through heterosexual contact; 51 (1.2%) through MSM; 65 (1.6%) through mother-to-child-transmission (MTCT); 1 (0.02%) through unsafe blood donation; and 332 (7.8%) via unknown sources.
As seen in the figure below, the total 4,298 registered HIV cases (including foreign citizens) from 1987 to 2013 are divided by mode of transmission: PWID (56.9%), heterosexual transmission (31.9%), unknown transmission (8.5%), MTCT (1.5%), and MSM (1.2%). The substantial “unknown” category may contain a significant number of MSM, as this behavior, as well as IDU, is stigmatized in Azerbaijan.
Taking undiagnosed infections into account, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) estimate that 9,200 (6,700-12,000) people were living with HIV in Azerbaijan at the end of 2013, 1200 (<1000-1500) people became newly infected, and less than 1,000 people died from AIDS-related causes during 2013. HIV prevalence in the adult population was estimated to be 0.2% (0.1-0.2%). The HIV prevalence among key populations, as noted in the Integrated Bio-Behavioral Surveillance Studies (IBBS) carried out in 2008 and 2011.
Investments in the national HIV/AIDS response
The National Strategic Plan for HIV 2016-2020 is currently under development. In its draft form, 5 key objectives are identified:
1. Implement evidence-based preventive activities focused primarily on affected key populations.
2. Ensure access to accurate diagnosis of HIV infection.
3. Expand coverage of ARV treatment.
4. Create an enabling environment for targeted HIV/AIDS interventions.
5. Develop program capacities, including human and infrastructural resources.
The expected outcomes of the National Strategic Plan are:
• a reduction in the spread of HIV infection among vulnerable groups (PWID, FSW, sexual minorities, and prisoners) by means of preventive measures;
• elimination of HIV transmission from mother to child through preventive measures;
• a reduction of mortality associated with HIV infection by means of early detection, treatment, care and support, and the extension of days lived for those with HIV; and
• a rise in public awareness of HIV/AIDS to reduce stigma and discrimination.
The Health Ministry has approved comprehensive Guidelines on Supportive Supervision of HIV for Service Providers. The Guidelines provide instruction for supervision to promote compliance with service delivery standards, and to promote improvements in the quality of HIV services.
The objectives of supervision of service delivery levels are as follows: a) to assist staff in providing improved preventive, promotional and essential curative services; b) to review health services coverage and quality and to assist in the implementation of plans and strategies for improvement; and c) to build capacity for self-assessment, problem-solving, solution-finding and solution implementation through guidance, support and on-the-job training.
Currently, the Azerbaijan Health Ministry is the Principal Recipient for the GFATM HIV Grant. The Project started in October 2010, and is expected to finish in September 2015, with total funds of €23.6 million. The 13 subrecipients include: a) the Republican Centre of the Struggle Against AIDS; b) the Main Medical Department of the Ministry of Justice of the Republic of Azerbaijan; c) the Scientific-Research Institute of Obstetrics and Gynecology; and d) 10 local NGOs. The GFATM HIV Grant in Azerbaijan has eight programme objectives:
1. Strengthening national capacities for effective responses to the HIV epidemic.
2. Strengthening HIV prevention among most at-risk groups through harm reduction.
3. Expanding access to HIV services in the penitentiary sector.
4. Improving knowledge and raising awareness about HIV among youth.
5. HIV surveillance, counselling/testing and laboratory diagnosis.
6. Expanding prevention of mother-to-child HIV transmission (PMTCT).
7. Scaling up anti-retroviral therapy (ART) and associated care and support.
8. Operational research in priority issues of HIV control.
According to the latest available GFATM Grant Scorecard, the HIV Grant has been successful in the following main areas:
• the decentralization and regionalization of ARV treatment (six regional centers were added in addition to the ARV centre at the National AIDS Centre);
• the establishment of Voluntary HIV Counselling and Testing (VCT) points throughout the country (43 points in various health facilities);
• the recruitment of social workers to work in the penitentiary facilities providing support for ARV treatment and HIV testing;
• the provision of palliative care for PLHIV;
• the amendment of the national PMTCT protocols (decreasing the number of tests for pregnant women from two to one) in the context of shifting the focus from extensive testing of all pregnant women to more targeted testing of the most at-risk groups; and
• the introduction of Life Skills Based Education at elementary and secondary schools and within the curriculum of the Azerbaijan Pedagogic University.
According to the US State Department, anti-discrimination laws exist but do not specifically enumerate lesbian, gay, bisexual, and transgender individuals. Societal intolerance, violence, and discrimination based on sexual orientation and gender identity remain a problem. In terms of prisons, the government undertook significant efforts to improve detention conditions by building new facilities and modernizing existing detention centers. The Interior Ministry reported the opening of five new detention facilities and the renovation of eight facilities in 2013.
General health care
The Azerbaijani government health expenditure accounts for 5.2% of the GDP (2011). According to the World Bank Group Azerbaijan Partnership Program Snapshot, the government has made substantial progress in rationalizing public health facilities and health care staff, developing treatment protocols, training personnel, and introducing family doctors and a licensing system for health professionals. Improvements are also being made to health care facilities through the construction of new regional hospitals and upgrading rural health centers, with a focus on strengthening primary health care.
Around 5,000 HIV-infected people were officially registered by the Republican Center for Combating AIDS in Azerbaijan from 1987 to July 2016, according to the Azerbaijani Health Ministry. Some 3,607 or 73.2 percent of them are men, while 1,348 (26.8 percent) are women. A total of 1,798 people already suffer from AIDS.
As to the causes of HIV in Azerbaijan, 47 percent of infected caught the illness due to the use of drugs, 42.1 percent through heterosexual and 1.8 percent from homosexual contacts, 1.8 percent are children infected by mothers, while one person got it through blood transfusion.
Over the first six months of the current year, 69,796 people were examined for HIV, while 44 of them were declared infected. Some 283 cases of HIV infection were recorded for the given period, including 180 Azerbaijani men, 96 Azerbaijani women and seven foreigners. The use of drugs is stated as the reason for 20.3 percent of HIV infection cases revealed in Azerbaijan during the first half of 2016.
Azerbaijani health expenditure accounts for approximately 5 percent of GDP. The government has made substantial progress in rationalizing public health facilities and health care staff, developing treatment protocols, training personnel, and introducing family doctors and a licensing system for health professionals. Improvements are also being made to health care facilities through the construction of new regional hospitals and upgrading rural health centers with a focus on strengthening primary health care.
Starting from 2005 provision of free of charge antiretroviral treatment (ART) was initiated in Armenia within the framework of ensuring universal access to HIV treatment, care and support. As of 31 December 2015, ART was being provided to all the patients with HIV eligible for treatment, who gave their consent for the treatment receiving (totally 941 patients, of whom 24 are children).
The follow-up of the HIV patients included provision of outpatient treatment, prevention and relevant laboratory testing for opportunistic diseases. The patients’ follow up includes regular monitoring of CD4 cell count and viral load, as well as complete blood count, blood biochemistry testing, diagnostics of OIs and of viral Hepatitis.
The National AIDS Center and NGOs provide social and psychological support to people living with HIV within the framework of care and support provision to them. Medical Mobile Team is functioning to make the services on HIV/AIDS treatment, care and support accessible for HIV patients residing in marzes. In-patient treatment of opportunistic diseases is provided within the state basic benefit package.
Management of coinfections, in particular of HIV/TB co-infection as well as the system of referral of patients with coinfections has been improved. System of referral of PWID for receiving substitution treatment is in place. ARV treatment is accessible for prisoners. Substitution treatment has been introduced for prisoners also.
The registration of HIV cases in Armenian started in 1988. By the end of December 2015, 2,247 HIV cases were registered in the country among the citizens of Armenia, including 42 cases of HIV infection among children. AIDS diagnosis was made to 1,167 patients with HIV, of whom 24 are children. Some 500 deaths were been registered among HIV/AIDS patients, including 8 children.
The HIV/AIDS situation assessment shows that the estimated number of people living with HIV in the country is about 3,800. Allocation of the HIV cases according to the years of registration shows that the number of registered cases has been increasing year after year until 2015, which was at maximum in 2014. During 2015, 294 HIV cases were registered and 161 cases of AIDS were diagnosed. On the whole, more than half of all registered HIV and AIDS cases have been diagnosed within the last 5 years, according to AIDS Response Progress Report.
The first characteristic feature of the HIV epidemic in Armenia is that starting from 2004 a change of main modes of HIV transmission can be seen. The proportion of cases of HIV infection through injecting drug use was reduced in more than 5.5 times in 2004-2015 reaching 12.2%, whereas the proportion of the cases infected through heterosexual contacts increased in more than 2.5 times reaching 78.2%.
The trend of increasing of cases of HIV infection through heterosexual contacts and decreasing of cases of HIV infection through injecting drug use is also observed among those infected abroad. The proportion of HIV cases infected through heterosexual contacts increased in more than 1.1 times in the last 5 years, and of those infected through injecting drug use decreased in 1.5 times. In 2015 the HIV transmission through heterosexual intercourse made up about 78%, and through injecting drug use - less than 17%.
Similar trend is observed among those infected in the Republic of Armenia (Figure 8). In particular, the number of cases infected through heterosexual intercourse increased and made up 81% in 2015, and the number of cases infected through injecting drug use decreased and made up 6%.
The second characteristic feature of the HIV epidemic in Armenia is the migration factor influence on the total number of HIV cases registered in the country (Figure 9). Thus, more than half of the HIV patients registered during 2009-2015 had been probably infected outside Armenia, of whom more than 90% - in Russia (91% in Russia, 5% - in Ukraine, 0.8% - in Poland, 0.7% - in Kazakhstan, 2.6% - in other countries).
In general, 57% of the registered adult cases in 2011-2015 were infected abroad, 13% - their sexual partners. Thus, 70% of cases registered in 2011-2015 are associated with migration. The third characteristic feature of the HIV epidemic in Armenia is that the proportion of so-called “classical risk populations” (PWID, SWs, MSM) in the total number of registered HIV cases has been reducing year after year starting from 2004. It was reduced in about 4 times within the last 12 years and made up 17% in 2015. The majority – 78.9% are the migrants and their partners, partners of the above-mentioned risk populations, those practicing unsafe sexual behavior.
The maximum number of HIV cases was reported in Yerevan, the capital: 733 cases, which constitute around 1/3 of all the registered cases. Shirak marz follows next - 258 cases, which constitute 11.5% of all the registered cases. The estimation of total number of HIV registered cases per 100 000 population shows the highest rate in Shirak marz – 104.7, followed by Lori marz, Gegharkunik marz, Armavir marz with the rates of 97.4, 70.8 and 70 respectively.
In 2014 estimations and projections related to the HIV infection were conducted in Armenia within the framework of the “HIV epidemic estimation and projection” process initiated and supported by UNAIDS. Those estimations showed that there are 3800 people living with HIV in Armenia, and HIV prevalence among people aged 15-49 is 0.2%.
Behavioral and biological HIV surveillance was conducted in Armenia in 2014. The surveillance results give the picture of the HIV epidemic in the country. Therefore, according to the data of the behavioral and biological HIV surveillance, 2014, HIV prevalence among PWID is 4%; HIV prevalence among SWs is 0%; HIV prevalence among MSM is 0.4%.