Community-based and community-led testing services are crucial in the HIV/AIDS, viral hepatitis, and sexually transmitted infections response, particularly in reaching populations where diagnosis and linkage to care are lower than the national average. However, providing these services can be challenging, especially in environments that may be hostile towards community-based and -led service delivery, and where policy and legal barriers exist.
In 2022-2023, the COBATEST Network supported six member organizations in countries where the environment is particularly challenging for community-based and community-led service delivery. In the following interview with Podruga Osh, one of the 6 organisation supported, we asked the organisation to tell us about their work, the challenges they face, and how they are working to improve community-based testing services for HIV/AIDS, viral hepatitis, and sexually transmitted infections in their communities.
Could you please tell us more about the specifics of the HIV epidemic in Kyrgyzstan and why you decided to focus your project on sex workers?
Despite the measures taken by governmental structures, non-governmental and international organizations, the number of HIV cases in the Kyrgyz Republic continues to grow, the number of which has more than tripled between 2011 and 2022 (from 3,673 cases in 2012 to 11831 as of 2022). In 2022, the number of registered HIV cases in the country is 11831, of which 680 are foreigners, and the actual number of PLHIV living in the country is 5498 (excluding deceased and foreigners), which is 68% of the estimated number. Cases of HIV infection have been registered in all regions of the country. The highest incidence of HIV infection in 2016 was observed in Osh city (2.6 per 1,000 population); in Chui oblast - 1.5; in the country as a whole - 0.8 per 1,000 population. In other oblasts, against the background of low HIV prevalence, there is a trend of rapid growth in the number of new HIV infections. The HIV epidemic is at the second - concentrated stage. This is due to its spread mainly among key populations at high risk of infection.
According to the results of a bio-behavioral study conducted in 2016, the highest HIV prevalence was recorded in three key groups: among people who inject drugs (PWID), 14.3%; men who have sex with men (MSM), 6.6%; and sex workers, 2%. In recent years, there has been a decline in parenteral transmission of HIV through injecting drug use, from 55% of newly identified PLHIV in 2011 to 25% in 2017, and a steady upward trend in sexual transmission, which amounted to 64% in 2017 (31% in 2011). The spread of HIV among key populations influences the growth of the epidemic among the general population. Thus, according to a sample survey (2013), 5.1% of sexual partners of people who use drugs were known to be infected with HIV, which largely determines the sexual route of HIV transmission in the country. .
Since HIV infection is concentrated among key populations, coverage of HIV testing of these individuals and their sexual partners will reach 90% of PLHIV who know their status by 2022. PLHIV do not apply or apply late for HIV testing. Thus, only 62% (5158/8307) in 2016 and 68% (5791/8500) in 2017 of the estimated number of PLHIV were identified. According to RCAIDS, almost one third of PLHIV (31.4%) in 2016 were detected in advanced stage of HIV infection with SD-4 cell counts less than 200, and more than half (62.1%) with cell counts less than 350 cells in 1 µL.
Between 2011 and 2017, the number of PLHIV receiving ART increased almost 15 times, from 229 to 3,237, but remains insufficient. In addition, due to high stigmatization and discrimination, unresolved social problems, there is low adherence of PLHIV to HIV surveillance and treatment. Thus, only 60.6% (3128/5158) of PLHIV are under dispensary care and only 51% (2668/5158) in 2016 and 56% (3237/5791) or 38% of their estimated number (3237/8500) in 2017 were receiving ART. According to preliminary data from the ARV resistance survey (2017), 52% of PLHIV were not taking therapy, 23% had drug resistance and only 23% had an effect from therapy.
In order to meet the objectives of the Kyrgyz Republic Government's HIV Program 2017-2022 to achieve the 90-90-90 goals, it is necessary to take a number of measures to reach key populations, to reach them with prevention programs and HIV education, and to provide support to receive the full range of medical and social services provided by the law "On HIV/AIDS in the Kyrgyz Republic".
Taking into account the fact that vulnerable populations (sex workers, transgender people, people who use drugs, men who have sex with men) are subjected to multiple discrimination from the general population, stigma from medical institutions, and gender-based violence, in 2012 the Ministry of Health of the Kyrgyz Republic adopted an order to introduce HIV saliva testing for vulnerable populations in nongovernmental organizations that work directly with the target group. The tests were purchased with the support of the Global Fund to Fight HIV/TB, and were introduced in HIV service organizations.
Thanks to rapid saliva testing, which has been introduced in nongovernmental organizations, many people from key populations have been able to overcome stigma and discrimination, freely use the services of organizations, and get tested for HIV in friendly organizations.
According to recent data from the Republican AIDS Center, in 2020, 233 PLHIV from among key populations in Kyrgyzstan were identified through HIV saliva testing. The peak was in 2018, when 442 PLHIV were identified. All identified PLHIV received quality post-test counseling, then they were followed up and placed on dispensary registration in the local AIDS center. At the moment PLHIV are receiving ARV-therapy at the local AIDS center. Only in 2022, according to the data of Osh AIDS Center, in Osh region, saliva rapid testing was conducted for key populations in the amount of 4997 people, 6 HIV-positive people were identified, only 3 of them became registered and started to take ARV therapy, which means that there is still stigma and discrimination against the target group in the society, that they are still afraid of persecution from the population and discrimination from medical institutions, which prevents them from registering in local AIDS centers. It is necessary to continue working with the target group to inform them about HIV transmission, HIV prevention, timely HIV testing, and to strengthen the work on adherence to ARV therapy.
Due to the COBATEST EECA region priorities for 2022, it became important to raise awareness about CBVCT services and/or HIV self-testing in communities where testing rates are lower than the national average.
"Podruga" decided to emphasize awareness raising on CBVCT services as well as HIV/STI prevention through information sessions for key populations, namely sex workers and transgender sex workers who live in hard-to-reach areas, cities, towns, which are more prone to religious influences and where our target groups are subjected to stigma and discrimination. Taking into account the fact that we already conduct HIV testing by saliva in our organization, we want to offer our target group to undergo assisted rapid HIV testing.
All work in the project was aimed at HIV awareness and prevention, assisted rapid HIV testing. Our organization can offer the community to undergo assisted rapid HIV testing in the organization or during outreach, to tell about sexually transmitted infections, about safe behavior.In case of detection of a positive HIV case, outreach workers will encourage the client to be registered at the Osh AIDS Center and start ART therapy. To avoid stigma and discrimination from the staff of medical institutions, outreach workers of the organization will help to provide social support to all clients to medical institutions if any of them is diagnosed with HIV infection.
What steps have you taken to reach the target population?
Our organization has been working for 22 years and we have established a trusting relationship with the target group, we have access to them. Outreach workers during the outreach visit tell about the services of the organization, about the services of the project, and the target group can easily come to us and receive services, not only testing, but also services of drop-in center, distribution of tools, as well as free medical examination for STIs, and free treatment for STIs. In addition, we have psychologist services, social support, domestic services (laundry, shower, food).
Did you encounter any difficulties during the project implementation?
No, we have not had any difficulties with testing, the only thing is that due to legal barriers we have reduced the coverage of testing of transgender sex workers , as they all hide in their apartments, changed their phone numbers, or migrated to other cities.
What is the status of the CBVCT in Kyrgyzstan and how does it affect your work?
CBVCT is based only on some NGOs that work in Kyrgyzstan, with such target groups as sex workers, PWUD, MSM. In our city of Osh there are only 3 NGOs that conduct HIV testing. One of them conducts saliva-based HIV testing among PWUD, the second one conducts saliva-based HIV testing among MSM, and our third organization, which conducts saliva-based HIV testing among sex workers and transgender sex workers.
Our organization has been conducting HIV saliva testing for 10 years. For this purpose, our staff have undergone specialized trainings on HIV testing and received certificates of training.
Testing is conducted on the basis of our organization, and it is very convenient, sex workers can come to our office for testing, as we have established trustful relations with them, or outreach workers can conduct testing in places of gathering, which helps us to cover a large number of the target group.
Is self-testing available and how popular is it?
In AIDS centers, it is possible to take a blood test, and blood testing takes place in laboratory conditions, on a paid basis. The tests are not available for free sale in pharmacies, the state cannot provide the tests to the population of the Kyrgyz Republic.
Therefore, self-testing among the population in the Kyrgyz Republic is not carried out.
At the end of May we started self-testing for target groups (sex workers, PWUD, MSM, transgernder people) in Osh. There are three ways to provide self-tests in Osh.
The first way is through GLOVO delivery, when the client can go to the website of HIVTEST. KG, fill in the questionnaire and order the test to their address. The second way through one testomat, which is located in the city center. And the third way, through a network of pharmacies in the city, donors USAID and ICAP CDC, which supply these tests.
These projects run until September 2024. Self-testing is still gaining momentum, but among sex workers and transgender people, traditional testing is still in place, when it is conducted by an outreach worker who comes to the places where the target group gathers.
Our organization disseminates information about self-testing among the target group, and there were a few people who ordered these tests through delivery. These were mostly from the MSM and transgender group.
What do you plan to achieve with your project?
To reach more target group (sex workers, transgender sex workers) from distant villages and districts with HIV testing, early registration in AIDS center in case of HIV detection and initiation of treatment and ART.
What gaps exist in HIV prevention in Kyrgyzstan and where communities could play a more active role, if they had such an opportunity?
Gaps exist in the legal environment. There is strong stigmatization and discrimination in the general environment towards the target group. Especially towards sex workers and transgender sex workers . They are beaten, abused, killed. there is strong discrimination against them in law enforcement agencies and medical institutions. Police officers are the main aggressors, who torture transgender people and MSM, blackmail them, sexually, economically and morally abuse them. Employees of medical institutions also show moral violence and may refuse to serve transgender people.
Our organization has experience in conducting trainings to reduce stigma and discrimination against sex workers among police officers. Taking into account our experience, with financial support we could conduct similar trainings for police to reduce stigma and discrimination against transgender sex workers.
This support was possible due to small grant programme as part of the project "Community Led and Based HIV Services - Key to Ending the HIV Epidemic in Europe and Central Asia" implemented by AIDS Action Europe, LILA Milano, and CEEISCAT in the framework of the COBATEST Network and supported by the "Zeroing In - Ending the HIV Epidemic" Programme funded by Gilead Sciences.