How the U.S. Government and Tajikistan Partner to Fight HIV/AIDS

An op-ed by Ambassador John Mark Pommersheim on the occasion of World AIDS Day, December 1, 2019.

The United States joins Tajikistan in observing World AIDS Day 2019.  Since 2003, the U.S. government has partnered with Tajikistan through the President’s Emergency Plan for HIV/AIDS Relief (PEPFAR), contributing $21.5 million in USAID programs aimed at eliminating the disease in Tajikistan.  Two U.S. agencies implement these programs in Tajikistan – the Centers for Disease Control (CDC) and the U.S. Agency for International Development (USAID).  PEPFAR’s life-saving work is made possible through the U.S. government’s unwavering commitment to the end the HIV/AIDS epidemic and the American people’s compassion and generosity.

There are an estimated 14,436 people over the age of 15 living with HIV in Tajikistan – amounting to a prevalence rate of 0.25%.  Out of this total, 10,662 are men and 3,774 are women.  In 2017, Tajikistan had 1,300 new HIV infections and 1,000 AIDS-related deaths.  Since 2010, new HIV infections have decreased by 2%.   As of November 2019, the Government of Tajikistan was providing life-saving antiretroviral treatment to nearly 7,000 people, representing 78% of all persons living with HIV who are aware for their status.  In Tajikistan, 70% of HIV cases fall in three areas – the Districts of Republican Subordination, Dushanbe, and Sughd Province.

Tajikistan continues to make progress towards the Joint United Nations Program on HIV/AIDS (UNAIDS) 90-90-90 goals by 2020:  to diagnose 90% of people living with HIV, provide antiretroviral treatment to 90% of those in need, and suppress the virus in 90% of those on treatment.  At the beginning of January 2019, there were 6,903 individuals aged 15+ diagnosed with HIV (which amounts to 48% of the estimated total); 5,313 of whom were on antiretroviral treatment (37% of estimated total); and 4,144 had documented viral suppression (78% of the estimated total).  The U.S. Embassy is committed to raising these numbers to 90% in each category through continuing assistance programs.

In Tajikistan, PEPFAR provides financial and technical assistance to both government and community organizations that are implementing programs to ensure all people living with HIV know their status and are accessing lifesaving treatment. This includes supporting community-based organizations that support vulnerable populations.

Tajikistan has made significant progress in implementing key policies to address to achieve these goals, including the provision of a single, once-a-day, generic pill known as TLD as the preferred antiretroviral treatment, and plans to administer this pill to 90% of people living with HIV in the next 12 months.  The first shipment of TLD procured by the Global Fund arrived in the fall of 2019.  We also want to take this opportunity to congratulate the Government of Tajikistan on the recent completion of a national survey that will provide valuable information about the needs of vulnerable populations and communities to ensure they can access lifesaving HIV services.

Nevertheless, Tajikistan faces several obstacles in achieving the targets of the initiative “UNAIDS Fast Track – Ending the AIDS Epidemic by 2030” and the 90-90-90 goals for 2020.  Key challenges include external migration and reduction in donor funding for health.  Another major challenge is discriminatory laws and policies toward key populations that limit access to and uptake of HIV-related services.  In addition, there is incomplete data about some of these populations, particularly migrants, and limited understanding of how they can best access services.  As a result, new case finding among key populations is lower than expected, and this population’s ability to find and use HIV services is limited.

In various communities, people living with HIV are targeted with stigma and discrimination, thus making it hard for people to be tested, in fear they will be met with negativity or imprisonment.  Considering that fewer than half of the people living with HIV in Tajikistan have been diagnosed, case identification is especially critical here, and it is important for those living with HIV to refer their partners for testing as well.

While clinical and health care settings are traditional venues to be tested, vulnerable populations who do not want to be stigmatized, will prefer community-based organizations.  USAID’s flagship activity utilizes peers to help reach people in need of treatment in key populations.

High rates of migration also make it difficult to find cases of people living with HIV. The World Bank estimates that almost 1 million Tajik citizens work outside the country at any given time.  These men most often work in Russia, where the HIV epidemic continues to grow.  Migrants are away from their families for extended periods, during which they are at increased risk of infection.  Exacerbating this problem is the fact that labor migrants are inaccessible to reach with HIV-related treatment while they are outside of Tajikistan.  This creates considerable barriers to reaching the 90-90-90 goals among this population.

The Republic of Tajikistan, in close collaboration with PEPFAR, the Global Fund, and other stakeholders, will implement new approaches to accelerate progress toward 90-90-90. These approaches include expanding effective community, peer-driven and facility-based case finding and testing strategies, and using real-time data to measure the effectiveness of programs and direct activities.  Tajikistan will expand and strengthen efforts to identify people living with HIV, and find partners, networks and communities where active HIV transmission is occurring.  In addition, the Republic of Tajikistan is working with PEPFAR on adopting and expanding strategies to ensure those diagnosed are linked to client-centered antiretroviral treatment services, and receive treatment at the community and facility level that help achieve viral suppression.

Sixteen years ago, when PEPFAR began, HIV was a death sentence in many parts of the world.  Now, we have the historic opportunity to make what once seemed impossible possible:  controlling and ultimately ending the HIV/AIDS epidemic, community by community.