Based on the Results of the Qualitative Study

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3. Analysis of the main obstacles and challenges to reach the targets by 2010.
4. Development of strategies and recommendations to address those obstacles and reach Universal Access by 2015.
Overview of the AIDS response in the country
Access of IDUs to ART remains a problem.
Human rights
Community sector involvement
Agreed Target Indicators
To prevent sexual transmission of HIV
To save mothers from death and infants from the infection
To eliminate punitive laws, policies, practice, stigma and discrimination hindering the efficient response to AIDS.
To improve social protection of HIV-affected people

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3. Analysis of the main obstacles and challenges to reach the targets by 2010.

Community members have noted a variety of problems hindering comprehensive and quality achievement of the goals set.

In 2010, the level of criminalization of the users of illicit opiates grew 20 times, which increases vulnerability to rights violation and restricts the access to medical and social programs.
Significant level of stigmatization and discrimination of MARPs is still in place.
In the country's regulatory documents, the data on HIV/AIDS program implementation are partially inconsistent with the targets set; the exact amount of people needing services is not defined making it difficult to evaluate the progress in achieving the targets.
Members of MARPs (IDUs, CSWs, prisoners, MSM) are insufficiently involved in planning, implementation and monitoring of programs.
While information is widely accessible, it is noted that young people do not fully understand the threat of HIV infection.
Lower accessibility and quality of medical and social services is notable in small towns and villages of Ukraine in comparison to oblast (regional) centers.

4. Development of strategies and recommendations to address those obstacles and reach Universal Access by 2015.

After the working meeting held on December 22, 2010, MARPs representative discussed the need of bringing in technical and financial aid to create and implement an advocacy program aimed at:

Increasing of the level and effectiveness of MARPs involvement into Universal Access provision processes in Ukraine.
Significant involvement into organization of transparent and integrated regular monitoring and reporting process for achieving existing and/or revised Universal Access targets by 2015.
Better interaction with the UN and other stakeholders at the country (and global) level.
Attracting more resources to support MARPs members’ involvement in programming, monitoring, policy- and decision-making.

SECTION 1:

General Information On The Situation In Ukraine

Overview of the AIDS epidemic in the country

The revised HIV/AIDS estimates show that as of the beginning of 2010, there were 360 thousand HIV-infected people aged 15 and older, living in Ukraine^¹⁴.

These data differ from the official statistics of registered HIV cases – 106,366 persons. The difference between the figures indicates that only 30% of people living with HIV have passed HIV test and know they are HIV-positive.

During the first six months of 2010 the incidence of HIV has increased by 6.0% as compared with the previous year. In the first six months of 2010, the prevalence of HIV among the citizens of Ukraine remained at the level of 2009 – 1.1%.

Death rate indicator is one of the main indicators describing the HIV/AIDS epidemic situation. In 2009, for the first time the number of AIDS-related deaths decreased as compared with the previous year – from 2,710 to 2,591 (from 5.8 to 5.6 per 100 thousand people). This is the evidence of the positive influence of large-scale ART implementation in Ukraine.

On the contrary, during the first 6 months of 2010, as compared with the same period of 2009, death rate from AIDS-related illnesses has increased by 29.6% - from 1,262 cases (2.7 per 100 thousand people) to 1,598 (3.5 per 100 thousand people).

AIDS epidemic spreading rate is ahead of the response: during the first six months of 2010, almost 23% of all new HIV cases were discovered due to clinical implications of the HIV infection^¹⁵.

The estimated data on the size of risk groups and PLWH confirmed by the National Council on TB and HIV/AIDS as of September 10, 2009^¹⁶ are as follows: IDUs – 290,000; CSWs – 78,000 (it is important to notice that the number does not take into account female IDUs); clients of CSWs (men) – 234,000; MSM – 95,000; prisoners – 145,000 people.

During the last four years (2005-2009) the number of new registered cases of HIV among IDUs remained virtually unchanged and amounted on the average to 7,088 people annually (6,282, 7,127, 7,088, 7,015, and 7,113).

Another high risk group is men having sex with men (MSM). From 2005 to 2009, a growing number of new HIV cases among the members of this group was registered annually: 20, 35, 48, 65, 94 (by years), including cases of AIDS. It may be assumed that the number of cases of HIV transmitted sexually among MSM is significantly underestimated because some cases are attributed to the other causes^¹⁷.

In 2008, for the first time since 1995, there was a change in the proportion of HIV transmission ways: the share of sexual transmission grew bigger than the parenteral one. However, IDUs remain the main source of HIV transmission, and the potential level of the virus penetration into a wider population is determined first of all by sexual transmission of the infection from IDUs to people not using injection drugs^¹⁸.

As there are no convincing, confirmed data indicating that the sexual transmission among general population causes most of the new HIV cases, Ukraine remains a country of concentrated epidemic, where HIV is confined to the risk groups^¹⁹.

Overview of the AIDS response in the country

Funding and budget allocation.

According to the estimated national expenses on HIV/AIDS response in Ukraine, the amount of money spent in 2007 was over 79.3 mln. US dollars (47 mln. US dollars – contribution of the state), and in 2008 – over 102.4 mln. US dollars (60 mln. US dollars – contribution of the state).

In 2008, 102.4 mln. US dollars were allocated as follows:

57% - treatment and care;
24% - prevention;
11% - program development and implementation;
5% - supportive environment and development of communities;
2% - staff;
1% - children made orphans because of AIDS and vulnerable children;
1% - research;
1% - social support and protection.

Development of communities and creation of supportive environment received 5% of the total amount in 2007 and 2008. This share includes funding of the programs for advocacy, human rights, institutional development in the field of AIDS and AIDS programs aimed at women^²⁰.

Main donors: GFATM (18.3 mln. US dollars – 2007, 26.8 mln. US dollars – 2008); United States Agency for International Development (almost 6 mln. dollars – 2007 and almost 8.7 mln. dollars in 2008), UN agencies (over 2.1 mln. US dollars in 2007 and 1.7 mln. US dollars in 2008), and others.

Part of the funds for ART programs, ART laboratory monitoring, blood donors and pregnant women testing, health care facilities infrastructure development etc. has been received from the state budget. A significant part of the funds is supplied from local budgets – this money is usually spent to finance health care, education and social protection institutions, offering various services to population on the local level^²¹.

TREATMENT

Most of the funds are spent for the "treatment and care" component, where government funds prevail. For example, their share was more than 31 mln. US dollars in 2007. As compared to previous years, activities of Ukraine in the field of treatment, care and support improve. For instance, the amount of ART increased 57 times: from 250 courses of treatment in 2004 to 14,256 as of November 1, 2009.^²²

Virtually all of the existing antiretroviral drugs and their generics are included into the National List of Essential Drugs and Medical Products. Antiretroviral treatment in Ukraine is free of charge and offered at the place of residence, normally at the AIDS centers.

The total need in ART is 25,380 courses as of July 1, 2010. ART is received by 18,836 persons (74.2%). There are 6,544 persons in need of the ART who do not receive it, and 67 of them are children. These figures account only for the patients currently registered for follow-up care.

Despite the fact that IDUs remain the main driving force behind the epidemic, their share among those receiving ART is as low as 7.7% (1,443 persons); this figure does not account for the patients who receive both ART and SMT simultaneously. Low number of IDUs among the people waiting for ART (the ones needing but not receiving the ART) – 12.6% (822 persons) – shows that this category of patients has limited access not only to ART, but to general medical care as well^²³.

Calculation of the need in ART^²⁴ is based on the outdated WHO recommendations, according to which indication for ART is CD4 <200. In the new WHO recommendations and the national protocol (MH order #551 dd. 12.07.2010) the criterion of ART prescription is CD4<350^²⁵. But the re-calculation of the need in ART has not yet been done and approved. It is expected that the re-estimation will lead to the needs growth by 40-50%.

Communities’ representatives have identified the following problems in the area of treatment:

Provision of support on the basis of registration address is a barrier for MARPs: "...The institute of registration is a serious problem in Ukraine. For example, if I am registered in the city of Kyiv but have no official residence registration there, I have no universal access. Even if I am detected to be HIV-positive, I will have to go and get medical registration in the city of my residence registration".
6,544 persons need but do not receive ART^²⁶. True accessibility of drugs remains restricted, especially for the people living in small towns.
There are difficulties with diagnostics for ART prescription: "...[The treatment is] Free! But before getting treatment you have to pass medical tests. The tests are done at clinic departments where they demand money for everything, if the clinic is not cooperating with some NGO".

• Inefficient use of the state funds caused by procurement of medical equipment, drugs and vaccines at excessive prices as compared to procurement made by Alliance-Ukraine and the Network of PLWH: "…making any decision takes very long time;[it can be explained by the fact] that they use corrupted procurement schemes and many medications do not receive the status of humanitarian aid".

The access to diagnostics and ART treatment in prisons is problematic: “...no CD4, no viral load testing, these tests are expensive, it is virtually impossible to pass them... ...If there are no test results, nobody will provide [treatment] to people”.
Access of IDUs to ART remains a problem.

PREVENTION

The state did not fund any prevention programs for vulnerable groups in 2009, and all the programs were funded with the money of GFATM and other international donors^²⁷.

On the one hand, there is information about the percentage of MARPs covered with the prevention programs in 2009: IDUs – 32%, CSWs – 59%, MSM – 63%, prisoners – 15%.^²⁸ But we were unable to find in the report any information about the numbers of those in need, used to calculate the percentages.

On the other hand, we believe that the efficiency of prevention programs among injection drugs users should be considered as low. For example, even the official number of the first time registered HIV cases caused by injection drugs use remains at the same level: in the first six months of 2010, 3,560 cases were registered, while in 2009 – 7,113 cases, in 2008 – 7,015 cases^²⁹.

It is necessary to mention SMT programs operating in all the regions of Ukraine. As of December 1, 2010, SMT programs covered 5,926 patients. The number of vacant courses in the program is over 1,600^³⁰.

According to the data received during interviews, risk groups members do have the access to prevention services. However, accessibility of a service may be limited due to the regional specifics: "the threshold of the SMT program is high: one has to submit documents confirming the fact of 3 to 6 unsuccessful treatments, and to pass many medical tests, both of which does not guarantee one being admitted [into the SMT program]."

Representatives of IDU/SMT community have identified the following barriers for SMT programs:

it was planned to establish SMT rooms in small towns but in fact there is no intention to do it;
medical workers have negative attitude towards the program;
community members have to get registered with drug treatment facilities which limits their rights and makes them vulnerable to abuse of power from the side of law enforcement agencies.
medical staff make admission criteria excessively strict.

Concerning the youth, the interviews allow to claim that this group receives sufficient messages related to HIV/AIDS, and everybody has or can get access to prevention activities and information. However, the access to such free of charge prevention materials as condoms and lubricants is restricted.

Young people make an emphasis on understanding of the risks and explanatory work in the society: "Actual social work with each group of population, beginning with the top echelons of authorities and ending with working people, with the people of toil. The whole society should be involved in fighting the HIV/AIDS epidemic."

Among the services for prevention of vertical transmission are diagnostics, provision of ART drugs and supply of infant milk formulas. As it was assumed, most of the barriers to access vertical transmission prevention exist among prisoners: "...even condoms are difficult to get in the penal colony." "Caesarean section is really expensive in prison, and they never do it, even knowing a girl is HIV-positive. So they make girls give birth without the operation, and children are born with the disease."

HUMAN RIGHTS

A number of regulatory documents in Ukraine protect rights and freedoms of people, including people living with HIV. There are general documents like the Constitution of Ukraine (art. 24) and the Law of Ukraine "Fundamental Principles of the Health Care Legislation of Ukraine". There are also specific regulatory documents concerning the protection of human rights of people living with HIV. In 1991 the Verkhovna Rada adopted the Law of Ukraine "On Prevention of Acquired Immune Deficiency Syndrome (AIDS) and Social Protection of Population". Some provisions concerning the rights of people living with HIV are included into the Law of Ukraine "On Information", the Criminal Code of Ukraine, and the Civil Code of Ukraine^³¹.

Despite sufficient number of the existing regulatory legal acts concerning HIV, the respondents in general either believe the level of their actual implementation as very low, or do not know about their existence. "The rights enforcement is insufficient; we have a right to free treatment, but it is not enforced, not all those who need receive treatment, and this situation is being aggravated".

MARPs and PLWH encounter significant level of discrimination at healthcare institutions: "The highest level of discrimination is among medical workers. It is the failure to provide medical aid. For example, a surgeon has to operate, but he says: "You may kill me or fire me, but I will not do it – I am afraid."

The Law of Ukraine "On Ratification of the National Program on HIV Prevention, Treatment, Care and Support of HIV-Infected Persons and AIDS Patients for 2009-2013" includes:

"Providing for control of observation of the HIV/AIDS legislation in the field of labor relations to overcome discrimination of HIV-infected people", i.e. measures aimed at the increase of awareness among PLWH about their rights and checking organizations’ policies for discrimination. According to the Program, in 2009 it is planned to check 120 enterprises, institutions and organizations. Meeting this objective cannot be checked because of the absence of information on the actions taken^³².

The interviews allow to conclude that some law-enforcement representatives' views on MSM behavior as deviant causes biased, discriminating attitude, which, in turn, is a barrier for prevention and treatment programs.

It is important to notice specificity of the target groups in terms of protection of their rights. Most of MARP community members have negative experience of interaction with state and law-enforcement agencies. Security of life and personal freedom should be the main priority for advocacy organizations: "...advocates or advocacy organizations either refuse to work with MARPs or demand open trials. However, in most cases such practice is destructive. People are afraid of victimization and revenge from the side of law enforcers after the "advocacy group" leaves the scene."

MARP community members believe it is necessary to implement programs aimed at elimination of the system violations of human rights (particularly the rights of patients) by representatives of governmental agencies.

SECTION 2

COMMUNITY SECTOR INVOLVEMENT

Target setting and review processes

The key issues raised during the interviews with community sector members and reflecting the process of community sector involvement are analyzed in this section.

To provide for consolidated decision-making to identify priorities in state policy, programs and actions with regard to fighting HIV/AIDS and tuberculosis in Ukraine, the following agencies have been established: the National Council on TB and HIV/AIDS and the Committee on Counteraction of HIV/AIDS and Other Socially Dangerous Diseases^³³.

In December 2010, the Committee was re-organized into the State Service of Ukraine on Counteraction of HIV/AIDS and Other Socially Dangerous Diseases and remains subordinated to the MH^³⁴.

As of June 7, 2010, members of the National Council on TB and HIV/AIDS include:

1 representative of the academic sector;
16 representatives of the governmental sector;
4 representatives of NGOs;
3 representatives of people living with the diseases: 2 – HIV, 1– tuberculosis;
1 – private sector;
1 representative of faith-based organizations;
2 representatives of country development partners: UN, US Agency for International Development;
1 member of the Parliament, 1 representative of trade unions (data collected from the country's Proposal for Round 10 to the GFATM).

One of the deputies of the Chairman of the Council is a representative of non-governmental organizations of people living with HIV. The deputy is elected at a meeting by the members of the Council^³⁵.

In the National Council there are no representatives of key affected groups (data collected from the country's Proposal for Round 10 to the GFATM).

Advocacy priorities are the issues concerning representation of IDUs, CSWs, MSM and prisoner communities in the National Council; issues of transparency of the delegation of authorities by communities to working groups and involvement of more people living in the regions of Ukraine into program planning, implementation and monitoring.

The main challenges identified by respondents during the interviews on the issue of community involvement process are the following:

Difficulties of involvement into creation of the national programs for community experts living in the regions: there is no funding for transportation and accommodation in Kyiv during the periods of reviewing laws, programs, and proposals. The work is done mostly remotely, without the possibility of personal participation in discussions, which decreases the level of influence on the decision-making process;
Formally, all regulatory acts in Ukraine pass the stage of civil discussion where any person or organization may submit a proposal. Nevertheless, there is no transparent and understandable mechanism taking into account the opinions of the community representatives with the subsequent transformation of such opinions into proposals to the regulatory acts;

There are no systems and long-term projects providing for the MARPs representatives participation in designing, implementation and monitoring of state policies/programs, including the ones accounting for advocacy strategy to scale up the influence of MARPs communities at all the levels of authorities;

We believe that insufficient participation of the regional MARPs experts causes the aggregation of indicators for populated areas of different sizes. Most of the interviewed community sector representatives think that the most serious problems of Universal Access and provision of a complete package of services arise in small towns of Ukraine. At the same time, the targets indicators are calculated in a way making it possible for the small towns to "get lost" in the overall number of the activities to be implemented.

SECTION 3

Universal Access

Agreed Target Indicators

In June 2001 Heads of State and Government Representatives gathered at the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS. At this meeting, the Heads of State and Government Representatives signed the Declaration of Commitment on HIV/AIDS^³⁶.

In April 2006, the ‘Road Map on Scaling-up Towards Universal Access to HIV/AIDS Prevention, Treatment, Care and Support in Ukraine by 2010" was created with support of UNAIDS.

There are national indicators for monitoring and performance evaluation of HIV/AIDS epidemic control (MH Order # 870 dated 28.12.2007, indicators conform to the UNGASS indicators^³⁷). The Order contains indicators, responsible agencies and reporting deadlines. However, we were unable to find information on targets used for the monitoring.

UNAIDS has identified nine priority areas to support countries in order for them to achieve the national targets on Universal Access^³⁸. In our country, the targets set are formalized by the Law of Ukraine #1026-17 dd. 19.02.2009 "On Ratification of the National Program on HIV Prevention, Treatment, Care and Support of HIV-Infected Persons and AIDS Patients for 2009-2013". The Program being an integral part of the Law includes detailed description of the targets.

Let us examine achievement of some of the target indicators of the National Program of Ukraine, most corresponding to the UNAIDS-recommended indicators.

To prevent sexual transmission of HIV^³⁹: coverage indicators related to prevention activities among vulnerable groups (IDUs, CSWs, MSM, and prisoners) as is stipulated by the National Program: 2009 – 20%, 2010 – 30%, 2011 – 40%^⁴⁰.

According to UNGASS data, in 2009 the coverage of prevention activities was as follows: IDUs – 32%, CSWs – 59%, MSM – 63%, and prisoners – 15%; the percentage of people who rendered sexual services for remuneration and used a condom in the last 12 months in 2008-2009 was 88% (sample group was 3,284 CSWs)^⁴¹. Estimated number of CSWs is 78,000^⁴².

To save mothers from death and infants from the infection: to reduce the percentage of cases of mother-to-child transmission of HIV from 7% in 2009 to 6% in 2010 and 5% in 2011 (targets of the National Program). In 2009, 94.9% of affected pregnant women received ART in Ukraine. However, in dynamics we can see the reduction in the number of cases of children getting infected by the HIV-positive mothers from 27.8% in 2001 to 6.6% in 2007. The total number of children with confirmed HIV status keeps increasing^⁴³.

To provide treatment for people living with HIV: to increase the number of children and adults receiving ART: in 2009 – 50% adults, 100% children; in 2010 – 60% and 100% respectively^⁴⁴.

Under the estimated data, in 2010 there are 360,000 HIV-positive persons over 15 living in Ukraine. According to the official statistics, as of July 1, 2010 there are 106,366 people with HIV registered, which is 60% of 171,661 HIV-diagnosed persons and 30% of the estimated number of HIV-positive individuals.

In 2009, 48% (74.2% of those who require treatment) of the adults and 100% of children receive ART in Ukraine. ART is free of charge, normally provided in AIDS centers with the use of generic medications. However, the death rate during the first 12 months after the beginning of ART (8.8%) indicates late start of treatment with low immune status. Less than 90.8% of those who began receiving ART had an access to CD4 testing, and among those 93.8% had CD4 lower than 350 cells per microliter^⁴⁵.

To prevent death from tuberculosis among people living with HIV. According to UNGASS report, in 2008 21% of HIV-positive people received tuberculosis treatment (data on the total number is unavailable). As of July 1, 2010 1,056 HIV-positive persons being tuberculosis patients are waiting to receive ART treatment^⁴⁶.

HIV prevalence among vulnerable groups in 2009: IDUs – 22.9%, CSWs – 13.2%, MSM – 8.6%, prisoners – 15.0%^⁴⁷.

To protect drug users from getting infected with HIV. Targets for Ukraine according to the National Program: 2009 – 20% (accomplished – 32%, UNGASS report does not state the total number clearly), 2010 – 30%, 2011 – 40%.

In the WHO/UNAIDS/UNODC guide on target setting in the system of developing targets for effective interventions it is recommended to take account of regular (at least once a month during the year) coverage percentage, accounting for comprehensiveness of prevention, treatment and care programs among IDUs^⁴⁸. In 2009, coverage of IDUs who applied to receive the services in Ukraine was 52% of the total number of 290,000 persons; 5,078 persons in 26 regions got access to SMT. IDUs have access to the following services:

distribution of syringes and condoms, HIV testing (voluntary counseling); hepatitis B and C testing, diagnostics and testing for sexually transmitted infections; trainings and provision of information literature, leisure organization and overdose prevention^⁴⁹.

The problem is that the harm reduction strategy does not take into account specifics of drug use: IDUs often receive (buy) drugs in syringes, and drug dealers make manipulations with their syringes in one common syringe; the information on possible harm reduction through change of precursors for preparation of psychostimulants/pharmaceutical drugs is not sufficiently used.

Myths about methadone harm spread among opiate-addicted IDUs and medical workers are a barrier for SMT implementation: at the moment, there are more than 1,600 vacant methadone-based SMT courses.

To eliminate punitive laws, policies, practice, stigma and discrimination hindering the efficient response to AIDS.

On December 23, 2010, the Draft Law on Amendments to the Law of Ukraine "On Prevention of Acquired Immune Deficiency Syndrome and Social Protection" was approved in the second reading^⁵⁰. Important achievements of the Draft Law are the provisions, which:

lift restrictions on the entry to Ukraine for foreign citizens due to their HIV status;
define clear and transparent procedures for access and testing for different categories of people – adults, children under 14, children aged 14 to 18 years;
provide HIV-positive people the right to receive additional reproductive technologies;
ensure protection of confidential information related to HIV status and its disclosure conditional upon informed consent of the HIV positive individual^⁵¹.

However, the new version of the Law supports controversial legal provisions of a discriminatory nature, such as:

criminal penalties for knowingly putting another person in danger of getting infected;
the right to deport foreigners or stateless citizens with HIV/AIDS, if their behavior endangers health, rights and lawful interests of the citizens of Ukraine^⁵².

Drug policies in Ukraine become more stringent: in 2010, the level of criminalization of the consumers of illicit opiates grew 20 times, increasing their vulnerability to violation of rights and restricting their access to medical and social programs; the future of SMT programs depends on the political will of the Government and regional authorities. For example, in Donetsk the City Council has forbidden to conduct SMT at the institutions belonging to communal property of the city, i.e. opiate-addicted IDUs may not receive SMT in hospitals of Donetsk.

"...today Ukraine has enough resources, in particular financial, to provide efficient response to the epidemic. Despite this fact, the situation is still the same: AIDS remains one of the biggest threats of the national scale. We lack commitment and pragmatism. Observation of rights of PLWH and MARPs should become one of the priorities of the HIV/AIDS epidemic response in Ukraine, because at the current stage:

the most vulnerable groups are get very little attention at the national level;
effective prevention, treatment and support programs are under the constant threat of termination;
human rights protection is seen as public health protection." Valery Ryabukha^⁵³.

To extend capacity of young people to protect themselves from HIV. According to the National Program, the share of youth involved into information campaigns in 2009 shall amount to 20% and in 2010 – 30%. According to the UNGASS report, the share of young people aged 15-24 years, who both correctly identify the ways of prevention of sexual HIV transmission and reject misconceptions about HIV transmission, was 40% of the total number of 2,602 respondents. We may say that this indicator has improved as compared to 2007, but in the last two years no major changes took place^⁵⁴.

To stop violence against women and young girls. In Ukraine, about 70% of women suffer from domestic violence, and about one thousand of them die as the result annually, though statistics does not reflect the actual situation because the problem is hidden from general public. Besides, criminal responsibility for employers refusing to hire pregnant women is not enforced, women receive lesser salary comparing to the salary of men doing the same job^⁵⁵.

To improve social protection of HIV-affected people

Chapter IV of the Law of Ukraine "On Prevention of Acquired Immune Deficiency Syndrome (AIDS) and Social Protection of Population" provides for social protection of people living with HIV and AIDS patients as well as their families. Article 17 of the Law clearly states that "HIV-infected persons and AIDS patients enjoy all the rights and freedoms guaranteed by the Constitution and the Laws of Ukraine". Apart from general rights, the Law also provides for the rights to:

• compensation of damages caused by the restriction of their rights which occurred as a result of disclosure of the information on those persons having been infected with human immunodeficiency virus;

• free provision of medications required to treat any diseases they may have;

• free provision of individual prevention means;

• psychosocial support;

• free travel to the place of treatment and back at the expense of the medical institution which issuing a referral to treatment;

• use of an isolated living room.

However, access to those rights is substantially limited: medical facilities do not wish to refer HIV-positive persons to diagnostics in order to avoid paying for their travel; HIV-positive individuals purchase the required medications at their own cost. The main problems of the insufficient social protection are low level of observation of the national-level regulatory documents by local executive services and underfunding of HIV/AIDS programs.

General revision of targets may be problematic even in case of reasonable necessity for such a revision as the list and the values of some of the indicators are fixed in the Law of Ukraine #1026-17 dd. 19.02.2009 which calls for a parliamentary procedure to revise the targets.

SECTION 4

Achievement of Universal Access Targets

The main problem of evaluating the progress in achieving some of the prevention and treatment target indicators is inability to assess the level of their achievement due to the lack of comparability of the targets and progress reports. Besides, the methodology of obtaining the information on the progress of program performance is unknown.

In the table below a list of targets and planned indicators stipulated by the Law of Ukraine "On Ratification of the National Program on HIV Prevention, Treatment, Care and Support of HIV-Infected Persons and AIDS Patients for 2009-2013" is shown. They conform to the UNGASS indicators^⁵⁶.

The figures illustrating achievement of the targets were taken from the National Program on HIV Prevention, Treatment, Care and Support of HIV-Infected Persons and AIDS Patients for 2009-2013 Progress Report for 2009^⁵⁷ and from the National Report on Monitoring Progress Towards the UNGASS Declaration of Commitment on HIV/AIDS (reporting period: January 2008 – December 2009)^⁵⁸.

No.	Target^⁵⁹	Indicators^⁶⁰		Performance in 2009		Comments
No.	Target^⁵⁹	2009	2010	MH Report^⁶¹	UNGASS^⁶²	Comments
1	Access of HIV-infected children and adults to continuous antiretroviral therapy through centralized purchase of ART drugs.	Children – 100%, adults – 50%	Children – 100%, adults – 60% (there are 50,000 patients in the Road Map^⁶³)	no single value	Children – 48%, adults – 100 %	Calculation of the need in ART is based on the outdated criteria (CD4<200)^⁶⁴.
2	Vertical HIV transmission rate.	7%	6%	data not available	data not available	No available data to evaluate the progress; UNGASS data for the year 2007 – 6.2%
3	Testing coverage, %: general population; members of the risk groups; prisoners.	no annual targets set	no annual targets set	-	-	No available data to evaluate the progress
4	Percentage of IDUs covered with prevention activities.	20%	30% (60% in the Road Map)	52% (of the estimated number of 290,000)	32%	In the WHO/UNAIDS/UNODC guide on target setting in the system of target development 60% is recommended as the target for the regular coverage (at least once a month in the course of a year)^⁶⁵.
5	Percentage of prisoners covered with prevention activities.	20%	30% In the Road Map: 70% of prisoners, in pre-trial detention centers - 100%	15% (total number is unknown) and 19.2% (of the estimated number of 139,653)	15%	The targets differ. As of September 10, 2009, the estimated number of prisoners was 145,000^⁶⁶: data on the estimated number differ.
6	Percentage of persons rendering commercial sex services covered with prevention activities.	20%	30% (60% in the Road Map^⁶⁷)	36.2% (of the estimated number of 69967 in the report)	59%	Targets and results differ and do not conform to the usual estimated data: 78 000^⁶⁸
7	Percentage of men having sex with men covered with prevention activities.	20%	30% (30% in the Road Map)	13.5% (from the estimated number of 95,000)	53%	Performance results differ
8	Coverage with treatment services: prevention, diagnostics and treatment of opportunistic infections of HIV/AIDS-related diseases	50%	60%	31,646 patients	no data	Targets: the basic number for calculation is unclear. Indicators do not allow assessing the progress.
9	Percentage of educational institutions which have teachers having passed the required training among their staff	8,000 teachers, 37% of educational institutions	8,000 teachers, 49% of educational institutions	1,662/4,000 teachers; 31%/58.7% of educational institutions	58.7%	Indicators of achievement in the MH report differ, progress is unclear.
10	Percentage of donor blood checked with test systems having passed a quality control	20%	30% (100% in the Road Map)	General data is not available	0%	Donor blood may not be checked for HIV with a guaranteed result.

Among the main barriers and obstacles on the way to achieving Universal Access community representatives indicate insufficient funding of prevention programs, corruption, and lack of explanatory work among population: "...some of the money allocated to fight AIDS is getting lost, Ukraine does not have proper systems to organize effective public service advertising. Everything is completely disorganized."

Another important barrier is prevailing narrow departmental interests over the interests of overcoming the epidemic and patients' interests, and also certain evidences of corruption. Such situation is seen by respondents everywhere – in hospitals, in the actions of law enforcement agencies, and also in general in the actions of organizations providing professional HIV services: "We now have more troubles since we have to pay 20 [hryvnias] to law enforcement officers in order to enter the flat [where illicit drugs are sold]. To exit, if you are carrying something with you, you've got to pay another 20 [hryvnias]… and so on"; "Lack of funding: 7 thousand people are not able to obtain treatment. But it is caused by corruption in the Ministry of Health. The allocated money could be used much better, but since there are, so to say, clans, which control the money, and get big cuts on all the purchases – well, the price could be much lower on the state procurement, and much more people would be able to receive the treatment."

Resume

Activities of all the sectors of Ukrainian society aimed at overcoming of and control over the HIV/AIDS epidemic are of contradictory, inconsistent and insufficiently coordinated nature. The main destabilizing factors are domination of narrow departmental and corruption interests over the interests of society and public health.

There are problems in assessing the level of progress in achievement of the Universal Access for key populations and prevention in Ukraine due to partial lack of comparability of targets in different regulations as well as of targets and progress indicators. Difficulty of progress assessment is also influenced by the absence of targets and performance reports; lack of coordination in the use of the estimated number of MARPs as a denominator (number of people requiring the service).
In order to achieve the Universal Access by 2015, it is required to:
- Revise prevention programs considering the adequacy of services and effectiveness of influence on HIV prevalence; involve youth into designing of informational messages in order to increase their impact on behaviour change; develop special services aimed at prevention of domestic violence and create a national strategy to improve women's situation in Ukraine.
- Decrease the level of criminalization, promote non-discriminating and evidence-based drug policy, including programs to improve health and human rights protection for drug users, direct efforts at eliminating systematic violations of human rights (including rights of patients) by representatives of governmental agencies.
- Fund projects aimed at involving MARPs representatives into development of state policies/programs. Purposefully collect the opinions from MARPs representatives to transform them into proposals to regulatory legal acts. Continue social mobilization; support the process of self-organization of key populations’ representatives.
- Keep on improving and extending activities of the National Monitoring and Evaluation Program with maximum involvement of the community sector members and their organizations (networks).
- Include representatives of youth as well as communities of IDUs, CSWs, MSM and prisoners into the State Service of Ukraine on Counteraction of HIV/AIDS and Other Socially Dangerous Diseases.
- Intensify and extend information programs aimed at rising awareness of the risks and threats related to HIV/AIDS transmission among youth.
- Facilitate further decentralization of services aimed at overcoming HIV/AIDS epidemic and neutralization of its consequences. In particular, facilitate further improvement of access to the services in small towns.

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Based on the Results of the Qualitative Study

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