Brussels, October 13, 2009
Latvia mediocre for HIV care and support, says new EU Index.
The care and conditions for people living with HIV/AIDS in Latvia are not bad but with some changes the outcomes could improve a lot, said the Euro HIV Index (EHIVI) 2009 which was presented today in Brussels. This first survey of HIV policy and best practice ranked Latvia 19th out of 29 countries, scoring 675 points from a potential 1,000. Luxembourg wins the ranking with 857 points followed by Malta (791) and Switzerland (775).
“Latvia could make a general improvement in every sub-discipline of the HIV Index, which would improve outcomes. There are two groups of people who need to be taken care of urgently: injection drug users and prisoners. Efficient harm reduction programmes need to be implemented. Today, HIV/AIDS care is affected by a reduction in the budget which creates a significant risk for deteriorating results in the future”, states Dr. Beatriz Cebolla, the Euro HIV Index Director.
While the number of people living with HIV (PLWH) increases in every member state of the EU, budgets in several countries are reduced. Sexual risk behaviour is becoming more and more regular practice. Criminalization of HIV is a problem in many countries, and still HIV specific legislation exists in some countries; people can get prosecuted also for unintentionally and unknowingly transmitting the virus. The access to care for marginalized groups such as undocumented migrants is not guaranteed almost anywhere in Europe. Discrimination and stigma against PLWH is frequent at work and in schools. Harm reduction strategies in prisons are still weakly implemented, especially in the Eastern European countries.
There is a general lack of leadership in HIV management and no government seems to know the true number of HIV-infected inhabitants. The main conclusion of the HIV Index is that there is still a lot to do.
About the Index: The EHIVI ranks the HIV situation across 28 indicators, covering 4 areas that are key to HIV: Involvement and rights, Access, Prevention, and Outcomes. The Euro HIV Index is compiled from a combination of public statistics, patient polls and independent research conducted by the founder, the Brussels-based think tank Health Consumer Powerhouse. The EHIVI 2009 takes a patient centred position. The Index is being held in association with the Swedish EU presidency of autumn 2009. It has received an unrestricted educational grant by Gilead Research.

To: The Presidents of Estonia, Latvia and Lithuania
The Parliaments of Estonia, Latvia and Lithuania
The Governments of Estonia, Latvia and Lithuania
International organizations and funds
the XIV Summit of the “Baltic Positive Network”
Svetciems, Latvia
August 30, 2009
                                              
                     POSITION PAPER
We, the representatives of ten non-governmental HIV/ AIDS organizations, gathered at the XIV summit of the “Baltic Positive Network” are addressing you. 
By voicing our position we draw your attention to what is happening in the Baltic States in HIV/ AIDS prevention and treatment under the crisis.
The economic crisis should not provoke worsened health and decreased availability of medical services for people living with HIV. 
The spread of HIV in our countries may go out of control provided the following actions are not implemented:
1.Prevention programmes for high- risk groups (harm reduction programmes inclusive) should become a priority, since HIV prevention costs much less than HIV infection’s treatment and fighting its effects.
2.Treatment of HIV infection should be performed only according to medical indicators, based on the World Health Organization European Region Clinical protocols, since treatment of HIV infection is its best prevention.
3.In order to use effectively the resources available, services provided should be patient- friendly and integrated.
4.In order to financially support prevention, treatment and care programmes for people living with HIV/AIDS, International structures and foundations should be requested, since the States’ resources are cut down.
5.Laws of municipalities should include the responsibility to decrease the transmission of HIV infection in their territories, as a governmental function.
We, on our part, are ready to support our States in HIV/AIDS prevention, treatment and care, and to participate in the process of reducing the costs of antiretroviral medication in our countries.
Signed by the representatives of the following organizations: Lietuvos Pozityvøjø Grupe, Pozityvus Gyvenimas, Demetra, Convictus Eesti, ESPO Ühing, Eesti HIV positiivsete võrgustik, Apvienîba HIV.LV, AGIHAS, DIA+LOGS, Феникс Плюс

6 June, 2009
Precedent in Latvia may be conducive to introduction of methadone maintenance therapy in Latvian prisons
On May 18, 2009 in Riga, a workshop initiated by the Baltic Office the UN Office on Drugs and Crime (UNODC) was held.
The agenda included such questions as accessibility of HIV testing, HIV-infection monitoring and its treatment in prisons in Latvia, and possibilities to ensure continuity of methadone maintenance for drug users therapy when there is convicted a person who had been the program client before the court dudgement.
Among the participants there were representatives of  the Health Ministry and Ministry of Justice, medical service from administration of penal institutions and women‘s prison Ilguciems, Publc Health Agency, Center on Narcology and Psychiatrics, four non-governmental organizations working in the field of HIV/AIDS.
28 persons undergo antiretrovival therapy in prisons currently, and according to medical evidence 56 more convicts are need in need of the therapy. The Latvian Center on Infectology states that for half of them the therapy is not yet recommended and the other half of them refuse to participate in therapy.
The issue of methadone in prisons has become acute because of the individual case: soon the court will bring out a verdict to the pregnant woman currently being treated with methadone. The issue of methadone in prisons has been in deadlock up to now because methadone has is included in the list of narcotic drugs but not included in the list of medications (methadone delivery to Latvia bases upon one-off approvals by the Ministry of Health).
During the meeting it was unanimously agreed that very case may be a good precedent for introduction of methadone maintenance therapy in prisons for patients who had been treated with methadone before conviction. Agreement was achieved on particular details: a prison will allow supplies of methadone to that very prison based on one-off permits to import some methadone for medical purposes. Together with that, a letter will be sent to the Ministry of Health asking to reassert that methadone as in case with psychotherapy – is a medication but not a drug. Besides, the Cabinet of Ministers has already received the amendments to corresponding Regulations №429. (EHRN/HIV.LV)

Threat of HIV/AIDS programs cutdown in Estonia
In another EU country the volume of services for vulnerable groups may decrease in relation to the poor economic situation.
Due to economic crisis, the Estonian government has decided to cut down its expenses in order to sustain the budget deficit within the European Union limits (according to Maastricht agreements, the latter index must not exceed 3 percent of GDP) in order to convert national currency to Euro.
Previously, The Central Bank of Estonia had forecasted economic dropdown by 12,3% in 2009. GDP slump in the last quarter of 2009 (9,4%) turned out to be unprecedented for the country for the last 15 years.
In view of threat of cutdown of HIV/AIDS programs, the Estonian PLWH Network, together with its strategic partners has prepared an official statement to governmental institutions. Statement was supported by other organizations working in the field: community ESPO, LIGO, AIDS Information and Support Center, „Sind ei jäeta üksi“ Narva Rehabilitation Center and Convictus Eesti.
In the statement, the Estonian PLWH Network points out that each person must be regarded important by the State. For the economic crisis not to cause new surge of HIV-infection (In Estonia last year the highest number of HIV cases in the European Union was registered), it is necessary to maintain funding of prevention programs. Despite the decrease in statistical data on new HIV-infection cases the crisis may reverse the trend.
“Our statistics shows what has happened quite recently”, Igor Sobolev, the head of Estonian PLWH Network, commented. According to him, all services and activities on HIV prevention should be preserved when economic crisis. “First of all, we should preserve the funding”. Yulia Kashina, the head of Advocacy Department of PLWH Network, mentioned that HIV and AIDS prevention, as well as HIV-infection therapy are much cheaper thаn removing harm caused by epidemic to the society. (EHRN/ITPCru)

1 June, 2009
Evaluation of the access to HIV/AIDS treatment and care in Latvia. Full text of the document see here>>>

A Report Prepared by Kees de Joncheere, Irina Eramova, Jenni Kehler, Ulrich Laukamm-Josten, Signe Rotberga, Anna Zakowicz and Roger Drew, May 2009. The mission was jointly supported by WHO and UNODC.

CONCLUSIONS

In order for a country to provide essential HIV-related services, including ART, it needs structures in place to allow effective leadership of the national response to HIV and AIDS. Such structures are not fully developed In Latvia. Stronger leadership is needed from the Ministry of Health and the State Commission on HIV and TB. Planned reforms to bring the prison health system under the management of the Ministry of Health are much needed. There is a need to urgently approve the new national HIV programme and its budget.

It is of grave concern that ART is currently only available to just over 300 people when the estimated need is between 700-1200. A key bottleneck in this regard is that AIDS treatment, care and monitoring is only available in one centre in Riga.  In addition, there is a need to focus on addressing the high default rate among those who start treatment through NGO-delivered programmes of adherence support. There is also a need for services which make it easier for IDUs to receive ART. The single, most critical step in achieving this is to expand the availability of methadone maintenance treatment both in the community and in prisons. There is a need for such services to be delivered in a well-coordinated way with the provision of ART, ideally in a common location.

Another concern is the unstructured way in which ART is currently being provided in Latvia. It is hard to explain why there are 67 different regimens for a relatively small number of patients. It is also unclear why so many PLWH are on ARVs recommended by WHO as second line and ‘salvage regimens’. Both these factors are resulting in an extremely inefficient use of resources. The average cost of ART is higher in Latvia than in other comparable countries. Alternative procurement practices need to be explored as they can lead to considerable savings.

There is currently unequal access to ART for different people in Latvia. In particular, it is more difficult for IDUs to receive ART than for non-IDUs. The most significant barrier to this is the very limited availability of methadone maintenance therapy and its complete non-availability in prisons. In addition, stigma and discrimination towards IDUs is widespread in Latvian health services. Financial barriers mean that unofficial ‘quotas’ are being operated as to who can receive ART. This is particularly problematic within the prisons.

Currently, patient monitoring is excessively focused on individual patient records with little aggregation of data for public health purposes. In addition, there is excessive reliance on inappropriate resistance testing in the absence of a fully-developed HIV resistance prevention and monitoring system.

Finally, there is relatively little integration of services. This applies both within government services, e.g. TB, HIV and drug services, and between government and NGO services.

RECOMMENDATIONS

1.Speed up the institutional reform of state agencies including revisiting the topic of prison health reform and the early adoption of the new national HIV programme. Part of this process included defining more clearly the roles and responsibilities of different bodies.

2.Scale up access to ART by decentralizing treatment outside of Riga through involving infectious diseases specialists of regional medical centres, involving NGOs in the provision of adherence support and coordinating more closely with essential services for IDUs, such as the provision of methadone maintenance therapy.

3.Promote more rational use of ARVs by reviewing the ARVs on the national drug list and merging outpatient and inpatient lists.

4.Adopt a more public health focused approach to ART. In particular, this would involve specifying:

The ARVs to use in first line, second line and ‘salvage’ regimens
Criteria to start ART
Criteria to switch regimens
Criteria for substitution of one ARV with another one.

This would require revision of the national guidelines in accordance with the WHO European Region clinical protocols on HIV/AIDS Treatment and Care. More training of health professionals is required focused on consistency of practice and efficient use of resources.

5.Obtain lower ARV prices by better procurement practices including increasing scale of purchases by reducing number of different regimens offered, using price comparison data in negotiations and direct purchasing from manufacturers abroad using existing legal mechanisms. Other options, such as using generics where patents have expired and where public health concerns merit it, should also be considered.

6.Take steps towards more equitable access to ART, particularly among IDUs. The most significant step that could be taken would be scaling up methadone maintenance treatment in the community and prisons. Measures are also needed to address stigma and discrimination experienced by IDUs in Latvian health services.

7.Adopt a more public health focused approach to patient monitoring. This will involve more aggregation of key data which would be made easier by the introduction of an electronic patient database. HIV resistance testing needs to be part of a more well-developed system on drug resistance, based on threshold surveys on transmission of drug resistance and observational cohort analysis of prevalence and incidence of resistance. Implementation of drug resistance tests at individual level is recommended after 2nd line ART failure. This will improve practice and offer cost savings.

8.Promote greater integration of services. In particular, this should focus on TB, HIV and drugs services. A big step forward would be co-location of ARV and methadone maintenance treatment. Greater integration of government services with those provided by NGOs, e.g. on ART adherence, would be welcome.

Association HIV.LV
For Immediate Release – Saturday April 25
(in PDF here)

Washington, Friday April 25, 2009 – Six Latvian organizations of AIDS fighters and people living with HIV have sent a representative to attend the General Assembly of the International Monetary Fund, April 25-26 in Washington, DC. They demand that Dominique Strauss-Kahn, Director of the IMF, uphold his December 23, 2008 commitment to protect Latvian health and social spending as part of the current IMF’s loan reimbursement plan. Latvian government imports of lifesaving medications, such as HIV drugs are currently under threat, as IMF loan recovery officers make a bid for all of Latvia’s foreign currency income.

LATVIA’s HIV CRISIS

Latvia is the EU Member State with the second-highest prevalence of HIV, after Estonia: 1% of adults are estimated to be living with the virus – over 10 times the EU average. There are more then 4400 (194 on 100 000 inhabitants) HIV infected people in Latvia (but according to WHO dates – 10 000), but only 334 gets the access to treatment with antiretroviral therapy. More then 400 patients in need of HIV treatment don’t have access, and the number of people in need of HIV treatment is expected to double across the next few months. The decision of Latvian government to cut the health budget for 40% means to cut money for HIV/AIDS patient’s medicine for 60% because there was already 20% decrease of expenses of ART this year. That is mean stop ART for almost all HIV/AIDS patients. Latvia also suffers from one of the fastest-growing epidemic in Europe. This snowballing epidemic situation requires immediate all-out interventions, starting with a 2-fold increase in treatment delivery and 2-fold increase in prevention services. Any cut to Latvia’s HIV fight budget would be literally deadly.

LATVIA’s IMF NEED

Latvian banks are currently at risk of defaulting on debt owed to Nordic and Western European banks. In 2006 and 2007, these foreign banks pushed unprecedented amounts of loans upon Latvian banks and companies: for several years, they lent the equivalent of 20% of Latvian’s GDP. Most of this lending was focused on speculative real estate operations, and resulted in an insane pricing bubble.

With the global burst of the stock and real estate bubbles in 2008, the EU loans to Latvian banks have now become unreimburseable, even counting on bank foreclosures on mortgaged real estate. Because of the sheer size of the foreign loans, the Latvian government doesn’t have enough money alone to bail out its defaulting banks. The Nordic and Western European banks are now afraid that, if they don’t get reimbursed from Latvia, they in turn might default on their own commitments. These EU banks have therefore asked the IMF to lend to the Latvian government, so it can lend to Latvian banks so they can meet the maturities they owe to EU banks.

IMF and Latvia

In an April 16 public statement[1], the Latvian Finance Minister revealed that IMF has threatened to withdraw €1.7bn worth of ‘rescue loans’ from Latvia unless the government increased the size of its budget cuts to 40%. IMF is demanding guarantees that Latvia will make reimbursement of IMF the priority use of its future foreign currency income. According to information obtained by Latvian AIDS NGOs from official sources, the Latvian budgets for importing HIV and other medications from abroad and for maintaining healthcare delivery are now both under threat. Latvians living with dangerous health conditions will die if these IMF threats come to fruition.

These recent IMF threats come in direct reneging of the IMF Director’s December 23, 2008 pledge (see www.imf.org/external/np/sec/pr/2008/pr08345.htm) that “Latvian social spending will be protected” and that it will even “increase by 1.5% percent of GDP between 2008 and 2009”.

Latvian activists call upon IMF Director Dominique Strauss-Kahn to uphold his December 2008 commitment to protect Latvian health and social budgets from IMF cuts, and to intervene personally to ensure that Latvians living with HIV or other healthcare needs may access lifesaving services in spite of IMF-mandated budget cuts.

Association HIV.LV:
Fenikss SI, Sun Island, Conscience Ecology, AGIHAS (PLWHA), Family Crisis Centre «Milgravis» and Youth against AIDS


April 22, 2009                                            
IMF HEADED FOR FAILURE IN RESCUE OF GLOBAL ECONOMY?
No Blank Check for IMF Without Real Reforms, Say Activists from Africa & Hard-Hit Latvia
Washington, D.C. — Just three weeks after the London Summit of the Group of 20 countries decided to make the International Monetary Fund (IMF) the primary vehicle for global economic recovery, civil society critics are charging that the programs it has instituted since the crisis struck could do more harm than good.  
On the eve of the semi-annual (“spring”) meetings of the World Bank and IMF, they are demanding that the finance ministers gathering in Washington change IMF rules so that emergency funds are delivered to vulnerable countries without damaging economic conditions, and without creating a new debt crisis.
Latvia has suffered most dramatically, with the IMF withholding a promised loan installment of $200 million last month because public spending was not being cut fast enough. “Our economy is falling apart — they say it will shrink 12 percent this year, our government has cut the budget by 40 percent but the IMF is demanding a ‘deficit target’ of 5 percent of GDP!  To reach this we will have to shut down our hospitals and cut pensions. People are scared, and they are taking to the streets to protest these draconian measures,” said Inga Paparde of the Latvian AIDS activist group Association HIV.LV.
But Latvia is not alone. Surveys of credit and loan arrangements for countries ranging from Pakistan to Malawi demonstrate that while the IMF is supporting fiscal stimulus for industrialized countries, it is demanding that most of the world cut public sector expenditures, hike interest rates, and reduce deficits — the opposite of the cure recommended for the United States and Europe . 
“This shipwrecked economy has tossed everyone into the waves, but the captains who led us into the storm are boarding the lifeboats while the rest of the world is getting left behind,” said Soren Ambrose, Development Finance Coordinator for ActionAid International.  “ Ethiopia , one of the poorest countries in the world, must hike fuel prices, cut public spending, and reduce its deficit. Ukraine must keep its deficit at zero. Belarus and Latvia must cut public-sector wages. Pakistan must raise its electricity rates. The list goes on and on.”
In Africa, people have long been accustomed to IMF budget and wage caps preventing their governments from spending what is needed to hire the teachers and medical staff who can provide basic life-saving and modernize agriculture from which over 75 percent of Tanzania derive their livelihood.  “Nothing has really changed with the crisis,” says Dr. Peter Bujari of Human Development Trust in Tanzania .  “Even with this externally-driven crisis that is driving down our export income, aid, and foreign investment, the IMF has given us no hope that there will be any financial stimulus, but only allowing some spending of aid originally diverted to reserves.”  
Less than 5 percent of the money on offer from the G20 is designated for low income countries specifically, and civil society groups are concerned that even these limited funds are planned in the form of loans rather than grants. Says Neil Watkins of Jubilee USA Network, “Because the money promised by the G20 for poor countries is in the form of new loans, rather than grants or debt relief, the IMF may be contributing to a renewed Third World debt crisis. Instead, the IMF should devote the majority of its planned sale of IMF gold to provide debt cancellation to poor nations, which countries urgently need to finance social services in light of the economic crisis.”
Robert Weissman of Essential Action points out that the IMF for the last 30 years has been a champion of policies of deregulation and liberalization that have fuelled this crisis. “The IMF took the logic that led to deregulation of the US banking sector and imposed it on most of the world’s developing countries. Its policies threw people out of work, reduced productive capacity, and starved governments of the capacity to provide basic services. By requiring that developing countries integrate into the global economy, they made them more vulnerable to today’s crisis. Developing country governments simply cannot afford more of the IMF’s medicine; they must demand the freedom to follow policies that protect their people from more harm, and the G20 leaders must listen.”   
Pointing to the education sector as an example of where the IMF’s impacts must be urgently addressed, David Archer, board member of the Global Campaign for Education stressed, “Investment in education is a crucial crisis response, yet it is currently an option denied to poor countries due to IMF policy advice, which constrains social spending.  Reform must accompany the new funding for the IMF so that responsible stimulus programs are not denied to the poorest and most vulnerable countries.”
Dr. Peter Bujari and Inga Paparde will participate in a media briefing on the afternoon of April 25.


Riga, 22 April, 2009
To International Monetary Fund. About critical situation in the Latvian health care.
Latvia's population, patients and organizations of medical professionals with deep concern follow the Latvian government's action in reducing government expenditures, which disproportionately limit the funding of the health care system. It should be stressed that in recent months, the medical care situation due to a decrease of finances is the rapidly deteriorating. This is evidenced by the sharp decrease in the number of patients’ visits to specialists, and patients' failure to appear for scheduled operations, as well as reduction of acquisition of state-paid medication for about 2 millions lats, etc. The government offered scenarios plan to reduce health care funding for 20, 30 or 40%. Patient organizations persuaded that the critical situation of patients to receive health care services created already when the spending of budget will be reduces by 20% - it means the major expenditure will again fall on the shoulders of patients. The Ministry of Health maintains that in this situation all ambulance services and examinations would then be billed to patients. Reducing the budget by 30%, means that patients would also pay a major part of hospital services, but cutting of 40% will bring to fully paid medical services. In this case state would be able provide only reimbursed medication, emergency medical care till hospital, health care for children and pregnant women. Further, the recently adopted by European Commission 2009 Joint Report on Social Protection and Social Inclusion recognized that Latvia is lagging most other Member States in terms of access to healthcare services, overall health expenditures and the general health status of population. Latvian population of health care in late 2008 officially recognized as the worst 33 European countries. Health care budget in Latvia is only 2.8% of GDP on average in other European countries it is 6-8% of GDP. Latvian patients have not possibility to insure their health as a result of illness the opportunity to receive health care services will be the only for person with high income or solid savings. At the same time, as result of the economic crisis in the country rapidly raise level of unemployment, declining income of population, which already limits the ability to visit doctors and buy medicine.
To prevent a further deterioration of patients’ situation of our country, the Latvian Umbrella Body for Disability and Patients’ Organizations SUSTENTO, which unites more than 30 000 members with a disability or chronic illness from 26 organizations, calls on the International Monetary Fund ensured that cuttings of budget made by Latvia government will not affect our people's health and lives. Special funds should be allocated to provide necessary health care services. This would avoid the health care system funding drain for contingency purposes, which is not acceptable in this critical situation.
Chair person of The Latvian Umbrella Body for Disability and Patients’ Organizations SUSTENTO Gunta Anèa.

23 April, 2009
To Mr. Dominique Strauss-Kahn, Managing Director, International Monetary Fund, 700 19th Street NW, Washington, DC 20431
Dear Mr. Strauss-Kahn,
During the G20 meeting in London on April 2, the Declaration on Delivering Resources through the International Financial Institutions stated support for a:
“doubling of the IMF’s concessional lending for low income countries and a doubling of access limits, within the Debt Sustainability Framework (DSF). We have committed, consistent with the new income model, that additional resources from agreed sales of IMF gold will be used, together with surplus income, to provide $6 billion additional concessional and flexible finance for the poorest countries over the next two to three years. We call on the IMF to come forward with concrete proposals at the Spring Meetings.”
In anticipation of the Spring Meetings, 25-26 April, in Washington DC, we call on members of the IMF’s International Monetary and Financial Committee and the World Bank-IMF Development Committee as well as any IMF committee tasked with developing proposals to fulfill on the G20 commitment, to ensure the following reforms are incorporated in the final proposal:
The IMF must phase out those activities outside its areas of core competence such as those of the Poverty Reduction and Growth Facility (PRGF). The IMF does not have a mandate for, or competence in, the long-term development of low-income countries. IMF resources channeled through the PRGF and from the proceeds of gold sales should support grant assistance or debt relief and be directed to an appropriate aid mechanism. The IMF's Policy Support Instrument (PSI) should also be phased out, in order to end the IMF's monopoly on 'signaling' to donors whether or not developing countries warrant support.
The IMF must eliminate harmful conditions linked with its loan programs and other instruments. The IMF should end its tradition of requiring countries to implement contractionary policies in economic recessions. For instance, the IMF should ensure that expanded investment in health and education are not subjected to overall budget caps and that subsidies that cushion the impact of the crisis on poor people are not eliminated. The IMF has made progress toward eliminating wage bill ceilings as conditions for lending, but it should stop this practice entirely. In addition, the IMF should stop directing countries to engage in privatization of services or financial sector liberalization through its loans and other instruments.
We also urge the IMF to open its consultations with Ministries of Finance to include Ministries of Health, Education and Development, pertinent parliamentarian committees with oversight on all related matters and civil society, in the development and finalization of proposals to ensure that going forward, IMF policies support countries’ efforts to scale up investments and access to quality health and education for all.
Sincerely,
UNDERSIGNED ORGANIZATIONS

13 March, 2009
Latvia "is working" while other countries are simply acting:
Narcological help office director of Psychiatry and Narcology Centre of Riga, Astrida Stirna reminds that all substances, which can cause inebriation, can not be prohibited. “There are substances the chemical contents of which we do not recognize and do not know. Nonetheless, inebriation can be proved both clinically and in the laboratory.
Prohibited substances have a certain standard, according to which its presence in the organism is detected. When adding to the list new substances, standard and procedure must be developed. Recently work is being done on salvia. People who are going to use something like that must remember that no one can guarantee its effects.
Possibly the effects will be lethal,” she concludes. To detect new intoxicating substances as quickly as possible, Europe warning system has been developed, into which Latvia is also included. Analytic in drug issues and warning system coordinator Public Health Agency (SVA) Linda Sile says that the most problematic situation is with smoking mixtures “Spice”, whose cannabinoid components are controlled in 3 countries – Austria, Germany and France.
Therefore SVA has prepared an official letter to the Ministry of Heath with a request to initiate a discussion, to seek a solution as to how to control these products. Until now they have been available in the respective home pages.  L. Sile explains that one of the solutions could be to prohibit import and retail of these smoking mixtures, similarly as in Austria, where it is prohibited when the smoking mixture contains one of the cannbinoids JWH-018. “Even thought, in Latvia these mixtures most often are not defined as “smoking mixtures”. They are generally sold as incense therefore it is hard to find basis, on which to take it out of sale or prohibit it,” acknowledges the expert.

13 March, 2009
PHARMACEUTICAL COMPANIES’ AGENCIES IN LATVIA ARE LOWERING HIV MEDICATION PRICES
The representatives of HIV patient interest advocacy organizations (Society AGIHAS, Society Association HIV.LV, Society DIA+LOGS) have been pointing out steadily and on different levels the inadequately high retail prices for specific HIV medication in Latvia, comparing other EU countries.
We have been discussing this issue by giving concrete numbers both at the (the Ministry of Health, Pharmaceutical Companies Association, Patient organizations) the members annual general meeting Trilateral Memorandum; at the Pharmaceutical Consultative Council; at Coordination Commission of Limiting Spread of HIV, TB and STD Infections, as well as in personal conversations with the Ministry of Health officials of different ranks. 
In this issue we have been heard by the World Health Organization (WHO) and United Nations Office on Drugs and Crime (UNODC) representatives in Latvia.
Irrespectively of the initially negative attitude shown from the head of the Coordination Commission (at the September, 2008 meeting), in the next Commission meeting in 2009, WHO and UNODC proposal to do investigation and analysis of this particular situation (and other complex issues – medical treatment schemes and accessibility etc.) was accepted. The Ministry of Health also acknowledged the investigation of this issue to be important and invited all the institutions involved to provide the international experts with objective information.
At this point, the technical task for the experts has been approved and it stipulates that the following associations are actively involved in the investigation process of the situation: Society AGIHAS, Society Association HIV.LV and Society DIA+LOGS.
It also has to be noted that the HIV medication purchasing budget for Year 2009 was noticeably minimized (from 2 513 514 LVL in Year 2008 to 2 160 000 LVL for Year 2009),  in fact, the minimization is even greater, taking into account the increase of the Value Added Tax (VAT) which this year increased from 5%  to 10 %. In the same way, the situation is even more complicated by the wholesale companies’ refusal to supply two cheap first choice medications for the initial Contract prices, because of the rapid rise in USA dollar exchange rate.
Under these circumstances, patients who receive HAART medication and whose medical treatment has been already started were under real threat, not to mention the new patients who need to start receiving medical treatment and whose condition is critical. (From 01.02.2009 The Latvian Infectology Centre provided medical treatment for 334 patients, even though twice as many infected patients are in need of it!)
Understanding the seriousness of the situation, as well as in order to care for the prestige reputation of the enterprise, company’s GlaxoSmithKline agency in Latvia in January of 2009 informed that they are reducing the retail price for the first choice medication Combivir by 43%.
Pharmaceutical Company Roche agency in Latvia also revised their HIV medication prices. In March of this Year Roche informed, that they are lowering the price for Invirase medicine by 10 %. It is possible that the letter sent by Association AGIHAS to all HIV medication manufacturing companies quickened this decision.
We will carefully follow up if this lowering of prices will allow LIC specialists to begin HAART medical care for new AIDS patients, whose situation is critical and who are entitled to the State guaranteed medical care.
In fact, all HIV medication prices could be lowered by 33 %, if parallel import and a direct medication supply without the help of mediator wholesale traders would be permitted.
Society AGIHAS Board Chairman Ivars Kokars
Society Association HIV.LV Board Chairman  Aleksandrs Molokovskis

12 March 2009
*Балтийское Позитивное Содружество*Baltic Positive Network*Baltimaade Positiivne Ühendus*Baltijas Pozitîvâ Sadraudzîba*Baltijos Pozityvus Susivienijimas*
Baltic Positive Network positions itself as an association/coalition of networks, organisations and groups, working on a meaningful and conscious involvement of people living with HIV into making decisions and into work.
In 1993 an informal Baltic Network of support groups for people with HIV/AIDS was founded, - the first network of the kind in the territory of Eastern Europe. On April 4, 2007 this Network was re-organized into Baltic Positive Network, into a status of an informal organisation. It was founded by five non-governmental organisations from Estonia, Latvia and Lithuania: Estonian Network of people living with HIV (Eesti HIV-positiivsete Võrgustik), ESPO Society (ESPO Ühing), Society AGIHAS (Biedrîba "Atbalsta grupa inficçtajiem ar HIV un AIDS slimniekiem"), Society Association HIV.LV (Biedrîba "Apvienîba HIV.LV"), Association Positive Life (Asociacija "Visuomeninë organizacija Pozityvus Gyvenimas").
The main goal of the Network is significantly increasing the role of HIV/AIDS non-governmental organisations in the Baltic States and increasing their authority in the eyes of the governments of these countries. The Network should develop a common relationship model with the government, taking into account each country’s particularities and create a system of political support for solving problematic issues in the lives of people living with HIV. The major goals of the Network are: mobilising and activating associations of people living with HIV in the Baltic States; coordinating activities in the spheres of prevention, medical treatment, care and support; situation follow-up and influencing the improvement of life quality for people living with HIV; development of strategies and common action plans to achieve a universal access to HIV/AIDS medical treatment.
The Chief Management of the Network is the annual general meeting of the representatives. The Network leadership is delegated from country to country for a time period of one calendar year. The head of the Network is selected by the Country in leadership. The head of the Network fulfils representational activity of the Network and executes operative tasks. 
The Network is open for new organisations to join in.
Baltic Positive Network website address is
www.ellpluss.org

03 March, 2009
DRAFT TERMS OF REFERENCE For the evaluation of the access to HIV/AIDS treatment and care in Latvia
Background:
Latvia has developed a new national HIV and AIDS strategy – “National Programme for Limiting HIV and AIDS in Latvia 2009 - 2012”. This national program document was reviewed through the ASAP mechanism by the UNAIDS co-sponsors in the end of 2007. The review revealed relatively high costs of HAART in Latvia, as well as obstacles for access to HIV treatment. UNODC has pointed to limited availability to treatment in prison settings and for injecting drug users (IDUs). In November 2008, the Association HIV.LV and Eurasian Harm Reduction Network (EHRN) called the Government of Latvia and WHO EURO to resolve the systemic problem of interruption of supply of HIV medication in Latvia. The main financial resources for implementing the national HIV program have been the state budget.  Whether lack of funding or inappropriate planning caused the treatment interruption is unknown.
The aim of the evaluation is to give practical input to Latvia for developing the area of HIV treatment and care in the near future, in the context of difficult economic situation in the country and limited resources for health sector.  For that the evaluation needs to assess and give recommendations on three main areas:
structures and systems in place,
coverage and quality of HIV treatment schemes (including cost-effectiveness aspects and compliance with WHO recommendations on AIDS treatment),
pricing and procurement policies of ARV therapy.  
Such an evaluation has been formally requested (through the CO) by the State Commission on HIV and TB and supported by the Ministry of Health as integral part of the collaborative agreement between the Government of the Republic of Latvia and the World Health Organization, and UNODC project “HIV prevention and care among injecting drug users and in prison settings in Latvia, Estonia and Lithuania”.

11 February, 2009
Association HIV.LV is anxious concerning the situation with medical treatment for AIDS patients
More and more patients whose immunogram for a long period of time has been showing cells 60, 50, 30 CD-4, and to whom the antiretroviral medication has been denied, are coming for advice, what to do in this situation. These patients are very worried about their life. Inga Januskevica - the head of the ambulatory division of HIV/AIDS at the Infectology Centre of Latvia, explained to us at a telephone conversation, that for the moment AIDS medical treatment is needed for 638 patients. 331 patients are receiving medical treatment and the priority of LIC is to ensure that these patients continue receiving the treatment. She explains: “There are also patients with 0 CD-4 cells and side sicknesses (e.g. tuberculosis), yet they are not receiving antiretroviral therapy, because otherwise the financial resources for this treatment would be exhausted by August of this Year 2009”.
While the solution for this problem is being looked for, the Association advises patients who have been denied AIDS medical treatment to do the following:
1) To submit a complaint to the Health Inspection, together with Xerox copies of LIC analysis;
2) To request from LIC doctors a written denial of antiretroviral therapy;
3) If, after the Health Inspection reviewing, medical treatment is still being denied, you may appeal the medication denials at the Administrative court.

31 January, 2009
UNODC organized regional AIDS seminar in Riga
(By: Larisa Abrickaja, EHRN)
In 2006, member-states of the United Nations committed themselves to scaling up HIV prevention and treatment responses to ensure universal access by 2010. To assist the Governments of the Baltic States in achieving this goal, the United Nations Office on Drugs and Crime (UNODC) in cooperation with the Ministries of Health implements a regional project "HIV prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania". The main achievements of the project in 2007 - 2008 were presented and discussed during a regional seminar "Universal access to HIV prevention and care by 2010: can we achieve it in the Baltic States?" which took take place on January 29-30, 2009 in Riga, Latvia.
The main objectives of the seminar were to exchange information about results achieved in each of the project countries, to present and discuss the recommendations of the mid-term evaluation of the project, as well as to discuss the priorities for 2009 - 2010.
The main issues addressed during the seminar were the sustainability of project activities and the current challenges for HIV response. The question of involvement of national agencies in the project activities in the future and introduction of 'sustainability assessments' into the assessment of small grants was on of the major topics given that the region can not continually rely on donor funding.
Promotion of further action on HIV in prisons and other custodial settings in the Baltic States was discussed. Estonian delegates expressed hope for methadone maintenance therapy (MMT) to start in 2 months in Tartu prison. Latvia and Lithuania committed to piloting MMT in at least one prison before the end of the project (however Lithuania suggested to introduce 1 month pre-release MMT which would be more realistic in terms of the project). Additionally, all participants of the conference agreed on establishing relevant monitoring and evaluation framework of the project.
Also, some new research data have been presented during the conference - including study on availability of syringes in pharmacies, study on prevalence of HIV and other infections and risk behaviour among IDUs in Baltic States and research on rapid assessment and response on drug use in few prisons.

 

Riga, 12 January, 2009
Regional AIDS seminar: UNIVERSAL ACCESS TO HIV PREVENTION AND CARE BY 2010: CAN WE ACHIEVE IT IN THE BALTIC STATES?

In 2006, member-states of the United Nations committed themselves to scaling up HIV prevention and treatment responses to ensure universal access by 2010. To assist the Governments of the Baltic States in achieving this goal, the United Nations Office on Drugs and Crime (UNODC) in cooperation with the Ministries of Health implements a regional project “HIV prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania”. The project aims to build national and regional consensus on effective strategies to address HIV/AIDS among injecting drug users and in prisons, to increase coverage of comprehensive HIV prevention services, and to generate and share strategic information on HIV/AIDS. 
The main achievements of the project in 2007 - 2008 will be presented and discussed during a regional seminar “Universal access to HIV prevention and care by 2010: can we achieve it in the Baltic States?”  The seminar will take place 29 – 30 January 2009 in Riga, and it will be attended by policy makers, drug dependence treatment and HIV prevention experts and non-governmental organizations. The main objectives of the seminar are to exchange information about results achieved in each of the project countries, to present and discuss the recommendations of the mid-term evaluation of the project, as well as to discuss priorities for 2009 – 2010. The seminar will also address the issues of sustainability of project results and the current challanges for HIV response. The working languages will be English and Russian.

Vilnius, 8 December 2008
Eurasian Harm Reduction Network: Latvia overcame HIV/AIDS treatment crisis
In November Latvia has faced another - forth and the most serious one for the calendar year - interruption in provision of antiretroviral (ARV) medicine to people living with HIV and AIDS. According to the latest news these crisis is now resolved not without substantial efforts of the non-governmental organizations. HIV/AIDS treatment is now practically resumed.
In the middle of November 2008 officials of Latvian Infectology Center announced that budgetary funds for antiretroviral treatment (ART) had ended up, so the interruption in normal provisions to people living with HIV and AIDS could last till January 2009.
Considering this problem non-governmental organizations have outlined an action plan and sent letters to the administrative office of the President of Latvia, State Compulsory Health Insurance Agency, Parliamentary Subcommission on Health and Social Affairs of the Sejm of the Republic of Latvia asking to envisage the issue of the interruption in provision of ARV to patients with HIV/AIDS. EHRN has also stated its concern about this problem in a letter to the Government of Latvia, the Infectology Center of Latvia and other governmental and non-governmental organizations.
Latvian authorities have paid attention to the actions of non-governmental organizations. On November 25, 2008 the State Secretary of the Ministry of Health A. Plorinysh said to deputies at the meeting of the Parliamentary Subcommission on Health and Social Affairs that the funds necessary to fully resume ART had been found in the Ministry's budget of 2008 owing to inner reassignment of the budget lines. Moreover on December 1 President of the Republic of Latvia Valdis Zatlers met with Boards' members of six non-governmental organizations, working in the field of HIV/AIDS, who expressed their concern about possible delay in accepting the decision to reassign the budget lines by the Cabinet in order to resume full access to ART the same week.
According to information provided by the Infectology Center of Latvia on December 3, the therapy had been gradually revived, though no official statements from the government was received. As of December 4, unofficial information was received saying that HIV/AIDS treatment is Latvia was practically resumed.
 
 
Riga, December 2008
World Health Organisation (WHO), the country office and the regional office, propose a mission to Latvia early in 2009
to check effectiveness of the antiretroviral treatment (ART) in this country. We ask WHO to involve in this process non-governmental organisations such as Association HIV.LV, AGIHAS и DIA+LOGS to study the situation with changing medicines, stop treatment for some period, stop ART at all. What they told people in these situations? Do they educate people on treatment about resistance? Do they educate physicians who treat people living with HIV (PLWH)? How? Why they have this situation with interruption for several years? Is the ART available for all PLWH who need it? How they reach PLWH who need treatment? Do sex-workers and intravenous drug users have any barriers to treatment? Why? Does PLWH receive peer-support on the treatment? Do they use best practices in HIV treatment approaches? What they think about UNGASS declaration and universal access? All these questions must be asked to Ministry of Health, physicians who prescribe treatment, epidemiologists, non-governmental sector and people on treatment.
 
Riga, November 2008
HIV/AIDS organisations in Latvia express a valid concern about shortage of medical supplies for HIV/AIDS patients.
Responsible institutions in Latvia – The Infectology Centre of Latvia, The State Compulsory Insurance Agency and other institutions, whose primary task is to provide HIV/AIDS patients with antiretroviral therapy medication, have brought a surprise „present” at the eve of  International AIDS day, celebrated in around the world on the 1st of December. This year’s slogan was: „Keep the promise! Stop AIDS!” Already for the fourth time this year, patients in Latvia have been denied antiretroviral therapy medication. According to information available to the Association HIV.LV, state budget money funds for this medication have been exhausted until January 2009.
„Changes in the usual rhetoric of doctors seem very interesting – they comfort patients with the few researches, which claim, that interruptions in therapy are harmless to the immunological state of the patient and are rather healthy. Not so long ago the same doctors were of a different opinion, and in cases when a patient skipped a few medication dosages or came for the medication to Latvian Infectology Centre Hospital a few days later, they were considered to be non-cooperating – such as do not cooperate in the process of medical treatment – and they were denied therapy,” points out the head of the board of Association HIV.LV Aleksandrs Molokovskis.
Information received from the patients indicates that patients are either given a different medication combination or are not given medication at all.
Medication availability problem was brought to attention at the last meeting of the State Coordination Committee for Limiting the Spread of HIV, Tuberculoses and STDs Infections, which took place on September 17, 2008, in Riga.
At this meeting, Infectology Centre of Latvia vice director Velga Íûse said that this year enough medication and timely ordering of medication for patients will be ensured”. This was a promise to HIV/AIDS patients.
Non-governmental organisations, representing the interests of HIV/AIDS patients, have sent a letter to the president of Latvia Valdis Zatlers, by informing him about the current situation with medication supply. Letters have been sent also to: State Compulsory Insurance Agency; to the Ministry of Health and Infectology Centre of Latvia about dissolving the problem of dispensing of medical supplies; to Latvian Saeima (Parliament) Health and Social Affairs sub-commission with a request to review urgently the issue about interruptions in supplying antiretroviral mediation at the nearest sub-committee meeting. Also announcements have been sent to the following international organisations: EATG, ITPC, ECUO, ITPCru.
 
Medication distributed to HIV/AIDS patients
Although, due to some bureaucracy caused obstacles, money for HIV/AIDS patients has not been allocated, HIV/ AIDS patients are already receiving medication at the Infectology Centre of Latvia (LIC).  Still, the government have not yet approved the commission project about money distribution to purchase medication for December, 2008.
Last week patient organisations eagerly waited for the decision of the government which would determine the budget redistribution, according to which approximately 200000 lats would be legally directed to LIC.  Yet this issue was not even at government's consideration.
Latvian Ministry of Health informs that there are money savings, which have been made from health care budget redistribution, so these savings come from economy on purchasing vaccinations.
Latvian Ministry of Finance has developed a commission project, according to which 207 000 lats will be granted to LIC for providing the increasing number of HIV/AIDS infected patients with the necessary medication.
This commission project has been sent to the respective Ministries for coordination. Once the acknowledgement on the issue will be received, it will be directed to the Cabinet of Ministers for reviewing.
Aleksandrs Molokovskis, the head of the board of Association HIV.LV, approved to the daily newspaper Neatkarîgâ Rîta Avîze that patients are in reality receiving their medical treatment again and for the moment not one patient has left the hospital without having received the medication. True thought, that some HIV/AIDS patients have been given medication only for 10 days but some for a month, as in the past. 
 
Medical treatment of HIV/AIDS patients in Latvia
Latvia uses 83 different ARVT combinations of medication for treating HIV/ AIDS.
The cheapest from the combinations costs 309 lats per month, but the most expensive - 2472 lats per month.
Treatment with the new generation medication costs 1496 lats per month.
Average therapy cost indicator for one patient is 638 lats per month and 7650 lats per year.
There are 2874 patients in LIC HIV/AIDS Department registration, out of which 630 patients are in AIDS stage.
1812 patients have HIV+ C hepatitis
159 children are registered, as born from HIV infected mothers, 29, 5 of them have AIDS.
350 patients are receiving the Specific therapy.
Prevention therapy is given to – 17 patients, among them – 15 pregnant women, 1 medical worker, and 1 other category patient.
Prevention therapy has been given to 427 patients, 253 pregnant women infected with HIV, 133 medical workers and 51 others.
 
Gaismas iela 19 k-8, 201, Íekava, Íekavas pagasts, Íekavas novads, LV-2123, Latvija

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