Fighting HIV in the Western Balkans - A forecast for 2020

Belgrade, 28 February 2020 - Despite the fact that all countries of the Western Balkans have low prevalence of HIV, statistics show a concentrated epidemic among GMT population as one of the groups most disproportionately affected by new cases of HIV infections. With exception of a few countries, which expect significant improvements, organisations in the region expect the year 2020 to show same trends. In light of such conditions, organisations are stepping up their outreach efforts, campaigns and advocacy work for provision of services and increasing access of PrEP and PEP as the best prevention mechanisms. Cooperation between LGBTI and HIV organisations across the region is satisfactory though there is ample space for improvement. One activist argues that HIV organisations should take the first step and engage LGBTI organisations in their awareness raising, outreach and advocacy work. Below is a forecast for the year 2020, with valuable feedback from ERA’s member and partner organisations in Albania, Kosovo, North Macedonia, Serbia and Slovenia.

Gay/bi men and men who have sex with men: A concentrated epidemic

Although the last bio-behavioural research was conducted in Serbia in 2013 by the Institute of Public Health, field data collected regularly by Rainbow Association reveal a concentrated epidemic among gay/bi men, men who have sex with men and trans (GMT) persons. Most alarming is that the newest infections occur among GMT persons younger than 25 years old. In North Macedonia, clear epidemiological data show that HIV is rising among GMT and this is the only key affected population in the country. In 2019, out of 66 newly diagnosed cases, 74% were MSM. In Albania, epidemiological data from 2019 reveal a total of 93 new infections out of which 2/3 were men. Sexual intercourse was the main form of transmission and 11.4% of them reported to be GMT. The report notes, however, that the number of GMT persons believed to be living with HIV is much higher, and that the high level of stigma against LGBTI persons, forces many not to disclose their sexual identity or sexual practices. In Kosovo, even though the number of new infections is not high, 3 out of 6 new diagnosed cases were GMT. In Slovenia, until 22 November 2019, the number of new infections was 25 and. It is not yet clear whether there is a decline in new infections compared to the year 2018 as organisations are awaiting the yearly 2019 report from the National Institute of Public Health. 

Expectations for 2020 

All respondent countries, expect the situation to remain the same throughout 2020. In Serbia, even though the pre-exposure prophylaxis (PrEP) drug has been introduced recently, its access to the community remains very limited and up until now it is available only in Belgrade. In Albania, the trend of new infections is not only expected to continue but it could become even worse during 2020. Organisation Alliance against Discrimination LGBT, which offers free and anonymous testing at its community centre, fears that the departure of the Global Fund as well as lack of adequate functioning of the Country Coordinating Mechanism will contribute to this. In North Macedonia the trend is expected to remain the same even though outreach and lobbying efforts of organizations like HE.R.A and Stronger Together have intensified and are expected to produce results. Kosovo expects the number of new infections to remain quite low, whereas Slovenia expects number to be stable or decrease.

Increasing testing and access to PrEP

Organizations across the region are working hard to encourage more persons to get tested and provide them with basic prevention services such as counselling, condoms and lubricants. In North Macedonia, organisations like HE.R.A. and Stronger Together are increasing their outreach efforts. There is a consensus among experts and key decision makers to de-medicalize HIV testing with rapid diagnosing tests and further increase the availability of the service. This includes not only testing by non-medical personnel but also the introduction of self-testing as a new preventing method which can reach far more persons than what is now available through different CSO programs. Such services are expected to start by the second quarter of the year. 

In Serbia, Rainbow Association is conducting outreach activities, especially with GMT persons who are vulnerable to HIV, such as those who do not have access to sufficient information, those who live in smaller and rural areas of Serbia and those who engage in social and coital relations incognito or in the surroundings such as “open” hotspots (public toilets, parks etc.) or “closed” hotspots (gay clubs, private sex parties etc.). The organization is using its specially equipped vehicle with the goal of making preventive and educational services and materials available to LGBTI persons. This outreach work has been combined with testing, informative and educational work in drop-in centres for GMT persons in several cities of the country. The plan is for these activities to intensify in 2020 and disperse them across Serbia. In Kosovo too, Centre for Social Group Development(CSGD) reports that after several years of bureaucratic and institutional obstacles a mobile testing unit has been set up, in order to provide this much needed service in other regions of the country. However, the organization is cautious in speaking about impact as work has just started. 

In Albania, for more than a year now, Alliance against Discrimination LGBT provides rapid testing, consultations as well as distribution of condoms and lubricants at its drop-in centre. Testing is provided also for many other sexually transmitted diseases such as hepatitis B and C, syphilis, gonorrhoea and chlamydia. The organization started making clear efforts to address HIV, as in the last few years it noticed new cases of HIV infections among GMT persons. The lack of targeted approach from state institutions prompted the organisation to act with urgency. While the organization has registered an impressive number of community members who have received testing and counselling, reaching out to GMT persons in other cities and towns remains challenging. Alliance will continue to provide these essential services during 2020 and it hopes to become part of the transitional funding in order to continue providing them further on. 

Organisation Legebitra in Slovenia is running a large HIV program, which includes counselling on sexual health, PrEP, Chemsex, community based testing, support for PLHIV and active HIV-related advocacy. They cooperate closely with health care professionals, policy-makers and other stakeholders. In recent years, they have been involved in important systemic changes which have benefited PLHIV and have a comprehensive overview on the situation surrounding HIV and PLHIV in Slovenia. In 2018, Legebitra’s community based HIV testing contributed to diagnosing 25% of new HIV infections among MSM in Slovenia, and the same programme was chosen by the World Health Organisation (WHO) as one of the best practices in the region. 

 Škuc Magnus also in Slovenia has a very ambitious goal to stop HIV in the next five years and take the number of new transmissions to zero. All their activities are multi-disciplinary and target GMT community, state authorities and other stakeholders. Tailor made interventions for GMT persons are being implemented regularly under the auspices of the HIV program Ustavimo HIV (Let’s stop HIV). Such intense efforts are being made to make PrEP accessible to everyone who needs it, to have it covered by the national health insurance, tackling stigma and promoting U=U as well as prevention and harm reduction of chemsex practices among other activities. 

Fighting for introduction and accessibility of PrEP

PrEP is now recognized as a highly effective drug for preventing HIV from sex or drug use and studies show that it reduces the risk of getting HIV from sex by about 99% when taken daily. It is now common knowledge that in countries like the United Kingdom, the high accessibility of PrEP for GMT communities along with early testing and proper treatment has dropped new cases of HIV infections to historical laws. 

Such success rates have prompted local organisations across the Western Balkan region to intensify their advocacy efforts and push governments to make PrEP available for everyone who needs it and have its costs covered by the national health insurance. 

Currently, introduction and implementation of PrEP remains full of challenges region wide. In Serbia, the drug is available only in Belgrade, it is not covered by the national health insurance and is not sufficiently promoted with the public or the GMT community. At the same time, information on PrEP is present within the GMT community, and many persons are already using it. They purchase the drug online and use it without proper professional instructions and monitoring. As such, many persons are using PrEP improperly and are engaging in unprotected sex, which bears a risk of acquiring not only HIV but also other sexually transmitted diseases.

In Slovenia, Legebitra reports that preparations are well underway and a study/trial is being conducted and processes of implementation and introduction are ongoing. Legebitra cooperates in these preparations as they recruit people at their own testing facilities for the ongoing PrEP trial. They are continuously updated about the progress of the trial and efforts in implementation of PrEP. Furthermore, as of recently, the organisation has launched PrEP communication services as part of their regular HIV/STI program funded by the Ministry of Health. Škuc Magnus also in Slovenia report that demand of the community for PrEP is great but in their assessment state actors are slow in delivering. More and more persons are buying PrEP online, which can become a great problem. PrEP advocacy will be a major focus for the organisation in 2020. 

In North Macedonia, preparations are underway to make PrEP available as an additional prevention mechanism. By the end of 2019, organisation Stronger Together initiated and led a process of developing national guidelines for PrEP and PEP including for cases of sexual exposure to HIV. 

Closer cooperation between LGBTI and PLHIV organizations as prevention, education and advocacy tools

It is understood that cooperation between LGBTI and PLHIV organisations is extremely important in terms of raising awareness, community outreach, advocacy work etc. This cooperation, however, is not always a given and while all organization acknowledge that good cooperation exists, many differences apply. 

In North Macedonia, while cooperation exists on various initiatives related to promotion and protection of human rights, challenges still exist. The existing gap in perceptions between the real risk of HIV on one hand and perceptions of the community on the other, shows that there is ample space for increasing mutual efforts of cooperation, especially on increasing community awareness and creating safe spaces for discussions and referral to HIV testing and sexual health services. According to organisation Stronger Together it is HIV organizations that should take initiative and steps to engage LGBTI organizations more. 

In Kosovo, Slovenia and Montenegro there are no perceived barriers between organizations many of which work very closely. CSGD in Kosovo, Juventas and Queer Montenegro in Montenegro and Škuc Magnus as well as Legebitra in Slovenia are some of the region’s NGOs which for many years provide integrated services and advocates equally for the rights of LGBTI persons and those of persons living with HIV/AIDS. In the case of Slovenia however, Legebitra points out that there are no specific PLHIV (only) organisations in the country and services provided to PLHIV and advocacy on their behalf is carried out by LGBTI organisations. 

In Albania, cooperation between LGBTI organizations and those working on HIV has improved significantly. Alliance against Discrimination LGBT and Albanian Association for Persons Living with HIVwork closely with and for persons diagnosed with HIV, with regards to counselling, access to services and other needs. In 2019, an informal group of organizations has been formed and its members are working closely together to lobby with national and international organizations.

In Serbia, while bilateral relations exist between organisations, and Rainbow Association itself works on both LGBTI and HIV, the level of cooperation is considered insufficient. Main reason for this, is the high level of stigma against HIV. According to Rainbow Association “Many clients of PLHIV organizations actively avoid cooperation with LGBTI+ organizations because of the fear that their HIV status will somehow be disclosed within the MSM community. Although they often use services of both PLHIV and MSM health or human rights organizations, but without disclosure of the information on their sexual orientation and HIV status. Therefore, the projects which would include the open cooperation between the organizations would, in the present circumstances, refuse many potential users of the services.”

Special report on Albania: State institutions fail to address the HIV epidemic 

ERA’s members in Albania, Alliance against Discrimination LGBT and Albanian Association of People Living with HIV/AIDS report a worrying and pessimistic situation. For years on, Albania does not purchase and import in a timely manner the necessary antiretroviral drugs, which need to be continuous and uninterrupted. As such, HIV patients are forced, during stock-out, to change their treatment schemes frequently, the consequences of which can be devastating for their health. Even though civil society organizations have continuously raised awareness and advocated against this problem, the situation repeats itself each year. To make matters worse, Albania frequently in the year lacks testing kits for CD4, viral loads and virus resistance, forcing patients to do such tests in private clinics with very high costs for most. In addition, local organizations report a total lack of awareness activities by the Ministry of Health and Social Protection, even less with the MSM population as a target. As a result, prejudices and stigma towards HIV remains very high among the LGBTI community and the rest of society, pushing many people not to get tested or to refuse treatment, very often leading to serious health complications and even death. While Albania prides itself as a low-prevalence country, the number of HIV related deaths in the country is alarming: 27 persons died in 2018 and 24 in 2019. LGBTI people remain the most affected key population due to double-stigma, fear of discrimination and exclusion.  To read the full report click here. 

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Author: Amarildo Fecanji, ERA

Contributors:

Aleksandar Prica, Rainbow Association, Serbia, 

Andrej Senih, Stronger Together, North Macedonia, 

Arbër Nuhiu, Centre for Social Group Development, Kosovo, 

Elizabeta Bozinoska, H.E.R.A North Macedonia

Lana Gobec, Legebitra, Slovenia

Livia Zotrija, Alliance against Discrimination LGBTI, Albania, 

Miran Šolinc, Blaž Brumen and Jernej Škof, Škuc Magnus Slovenia, 

Olimbi Hoxhaj, Albanian Association of Persons Living with HIV/AIDS, Albania, 

Xheni Karaj, Alliance against Discrimination LGBTI, Albania