HIV – the deadly virus invading the Baltic states

Date: 19/05/05

There might seem little positive to say about the trends in HIV/AIDS in the Baltic states. In Estonia, the rate of infection is, at 1.1% in 2003, above the threshold at which the spread of the disease is expected to explode (1%). In Latvia, it is 0.6% (though some estimates are higher, some lower) and it is spreading fast in the heterosexual population. Only in Lithuania is the disease at an untroubling level (less than 0.1%).

But Latvia does offer some positive news. For the past three years, the number of new HIV cases has been dropping each year by 30% (323 joined the list in 2004). Although the infection is now in the mainstream of Latvian society, its impact is being contained and reduced.

The most significant drop has been in the number of intravenous drug users contracting HIV, from 82% of all new infections in 2001 to 73% in 2002 and 57% in 2003. This understates the role drugs play in spreading the disease but is nonetheless a dramatic improvement in what is, numerically, the most at-risk group in the country.

Part of the decline may be attributable to a new commitment to informing Latvians about HIV, but it also reflects what amounts to a breakthrough in the country's approach to the problem: the greater involvement of local governments.

1991 was, in many ways, 'Year Zero' for Latvia. HIV/AIDS had begun to surface as a problem in the last months and years of the Soviet Union, but in the first year of independence the country had other battles on its hands. Central government had to plan a transformation of the country while its revenues were tumbling; local government was acquiring new powers but had little money to deal with huge problems; and civil society had no recent history of public involvement.

The anti-AIDS effort suffered as a result. Central government spent most of its HIV/AIDS budget on treatment and very little on prevention. Local government did almost nothing to treat or prevent HIV/AIDS. Those who were concerned about preventing the spread of the disease - supranational organisations (such as the United Nations Development Programme) and bilateral donors therefore looked to fledgling non-governmental organisations (NGOs) to work on prevention.

Donors made considerable efforts to build up civil society. Their help was crucial since the state provided no subsidies to NGOs (except those working in sport). Public-private partnerships produced little; dealing with HIV and high-risk groups is simply too unattractive, and sometimes too controversial for potential partners. So, when donors did not renew grants, the NGOs working on HIV/AIDS and drug-related issues faded away.

What had been created was an unco-ordinated system where most of the prevention efforts depended on young, weak organisations whose financial health was vulnerable. NGOs filled a gap in an area under-funded by the state but, without public support, could not fill the gap in the long term.

In the meantime, rates of infection climbed. Most of the government's budget for prevention was spent on information campaigns targeting the general public rather than specific groups. But playing on fears had only limited effect, since many did not seem to feel fear. Olga, an intravenous drug user in the mid-1990s, was unconcerned. "At that time there was no information about the possibility of getting AIDS from injecting drugs." She recalls that, for her and her husband, "the HIV problem seemed to be far away - in Africa rather than here".

But by 1997 the infection began to spread rapidly, after the first cases were recorded among intravenous drug users (40,000 in a country with a population of 2.3 million, according to 2002 data). By 2001, the number of new HIV cases was almost twice as high as in 2000.

Just as infection rates were accelerating, it also became clear that the prospects for grants to NGOs were declining.

Since 2000, there has been an effort to incorporate one key player in dealing with HIV: municipalities. In the 1990s, the local authorities' role was largely restricted to granting permission to NGOs to operate, and - if the NGO was lucky - the free use of premises. In two or three cases, in Riga, the capital, local government also provided some money.

In 2000, the Latvian government and donors began talking with the local governments where HIV and drug use are highest about setting up a small, pilot network of eight drop-in centres for high-risk groups, particularly drug users. Few local communities were willing to become involved. Drug abuse was not a priority forlocal officials; for them, unemployment, schools and access to medical care were more burning issues. Nor were many of them willing to become too closely associated with a disease shrouded in myths.

But the drug users' way of life meant that, at some point, this high-risk group calls on local services in any case. Olga, who is no longer a drug user, describes the seasonal pattern.

"Drug use decreases during the winter and spring, and then again in summer it increases," as "many users go to rehabilitation or treatment clinics during the winter, because they don't have any income and sometimes no home". There are other local costs, since many drug users are involved in crime of some sort.

It took a long time to convince local councils that action was needed and a year and a half for the project to start. Even the city with the second-highest HIV rate, Ventspils, was reluctant to join the network. The council did not want drug use to be seen as a problem in the city.

What the programme sets up is a system in which the local government (or, in Riga, an NGO) provide services aimed at prevention and the state in effect controls the quality of the service by co-ordinating the whole project and activities at the national level. Donors continue to play some role: their money is being used to expand the activities of the whole network and individual centres, which are otherwise limited to high-risk groups and providing information to the general public.

The programme means that the various levels of government and the non-governmental sector all have a responsibility and a sense of ownership in the project. This more decentralised system brings programmes closer to the source of the problems. (In Jurmala, a famous seaside resort, the centre has, for example, bought a minivan to take its service out onto the road, into remoter areas.) A more co-ordinated system means that services are delivered to more communities, funds are shared out and allocated more efficiently, and trends in the spread in the disease are monitored better.

Olga, who has been raising awareness of AIDS issues among drug users for six years, believes the impact has been significant. In 2003, the centre she worked for lost funding from its donor, but the municipality offered resources and the centre continued as part of the HIV/AIDS prevention network.

"I can imagine that the number of HIV infections would be twice as high as it is now", she says. "They would not know the risks. With support from NGOs we can offer tests, syringes, encourage people to take treatment and try to ease access to therapeutic medicines." The response, she says, is very positive.

Since 2002, when the project went nationwide, 5,992 people have sought advice, tests, or syringes from the centres (most have come back roughly ten times).

The network is expanding (13 such centres have been operating by end of 2004), but so is the disease. The 3,113 families in Latvia affected by HIV still live mainly in large urban areas and along the country's main transit routes, but HIV has now also reached small towns and remote districts. Prevention is, more than ever, a national task.

• Ilze Jekabsone is a programme officer for the UNDP in Latvia. A longer version of this article first appeared in the online magazine Transitions Online (www.tol.org).

Major analysis feature in which the author, who is a programme officer for the UNDP in Latvia, takes a look at the spread of HIV and AIDS in the Baltic States