Neweurasia has launched a new series of topic-specific posts across all of the country blogs in an effort to provide readers a comprehensive overview of current policy issues in Eurasia. We have devoted this first discussion to HIV/AIDS in the region. Thanks to all of our bloggers, you can find a country-specific overview in each of the country pages:

Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan.
UPDATE 24/04/06: Luke has posted a relevant post on the Mongolia blog.

Here on the homebase, we want to step back a bit and examine the issue from a regional perspective and discuss the following questions:

1) What are the defining characteristics of the regional epidemic and how does this differ from other regions?
2) Where does HIV/AIDS fit in the context of the region’s overall health and development challenges?
3) What should governments and donors be doing to combat this problem?

The World Bank, which launched a $27 million Regional AIDS Control Project in Central Asia in May, has published Reversing the Tide: Priorities for HIV/AIDS Prevention in Central Asia, as well as an accompanying brief available online. In general, the AIDS epidemic in Central Asia – and to a lesser extent the Caucasus – is centralized among intravenous drug users (IDUs), especially among prison inmates, and has more recently started to spread through the commercial sex sector. Although Central Asia’s epidemic is indisputably growing (from about 500 cases in 2000 to over 12,000 in 2004), unlike many other developing regions – Africa in particular, but also South Asia and Latin America – it is still quite small and concentrated in these at-risk populations and has not yet entered the community at large, with a prevalence rate less than 0.3% in most countries. On one hand, this relatively low prevalence would suggest that the huge amounts of donor resources devoted to ‘vertical’ HIV/AIDS programs in the region are unwarranted, given how disproportionately large they are compared to other health and development priorities. However, there is a compelling counter-argument that it is the low prevalence itself that justifies the substantial donor monies because there is still the opportunity to halt the spread of the disease before it enters the broader population through targeted prevention efforts now, reducing the need for expensive – and ultimately unsustainable – antiretroviral treatment programs further down the line.

In either case, though, the international community needs to be careful not to fund HIV/AIDS prevention and treatment at the expense of the broader health system and infrastructure, whose post-Soviet legacy renders it quite different from the other settings with which donors are more familiar. Throughout Central Asia, there is actually excess medical capacity where underused hospitals and medical personnel make up a disproportionately large share of the health budget (although recent efforts have successfully sought to address these inefficiencies). This is in stark contrast to other AIDS-endemic countries, which suffer from a shortage of health facilities and human resources, and thus represents a fundamentally different set of challenges for prevention and treatment efforts and opportunities – particularly as donors strive to simultaneously work within and strengthen the overall health infrastructure through HIV/AIDS programs instead of creating parallel systems.

So where should the international community focus its efforts? First, through facilitating needle-exchanges (which Kyrgyzstan has already experimented with in its prisons), and second, through targeted outreach to commercial sex workers. Neither program requires expensive equipment, new clinics, or staff – and are thus not only ideally suited to the epidemiologic characteristics but also to the existing health capacity in the region. But both programs, unfortunately, are ineligible for U.S. funding, which represents a huge obstacle given that the U.S. policies guide not only its bilateral donations but also influence multilateral funds to which it contributes, including the World Bank and the Global Fund to Fight AIDS, TB & Malaria (for a more detailed discussion of U.S. policies on commercial sex workers, see here). And together, those are the three largest sources of AIDS funding in the region. The more ‘politically palatable’ programs such as antiretroviral treatment, abstinence education, and even condom distribution (relatively speaking) are just not as relevant in Eurasia as they are in Africa or South Asia. At least not yet – and it is up to the donors to make sure their funds are used wisely now to prevent the epidemic from reaching those proportions in the future. Conversely, it is also critical that they don’t devote too much health funding to what is a still relatively small problem at the expense of neglecting more basic and less ‘sexy’ public health problems such as lung cancer, alcoholism and high blood pressure – which represent the much more critical development challenges in the region today.