: AIDS in Azerbaijan

The prevalence of HIV in the Republic of Azerbaijan is currently low, but the rapidity of the epidemic's spread is alarming. The first case of HIV infection was registered in 1987 non-citizen, the first case in a citizen was registered in 1992. As 1.07.2008 the number of officially registered cases was 1572 of this group, 315 people have developed AIDS and 220 have died. Moreover, according to local and international experts, the realistic estimated number of PLHIV is approximately five times higher than the number of officially registered cases.

Azerbaijan is currently facing a 'concentrated' HIV epidemic with a very low overall prevalence among the general population (0.008% out of 8,266,000 people) but a high prevalence among key populations that are particularly vulnerable to HIV infection: 60% among injecting drug users (IDUs).

The dominant mode of transmission is injecting drug use (60% of all cases) followed by unprotected heterosexual contact (21,2%). Transmission via unprotected sexual contact between men who have sex with men (MSM) accounts for 0.8% of cases; mother to child transmission (MTCT) 0.1%; and via blood transmission, 0.1%. It is worth noting that in 18.1% of the cases, the source of infection is unknown.

The rapid increase in new HIV infections (and also STIs) in Azerbaijan is directly related to the increased number of injecting drug users. Although the epidemic is concentrated among IDUs, especially along the drug trafficking routes, an increase in the reported number of CSWs and migratory population has created a situation where the epidemic could easily spread to other parts of the population.

The dramatic socio-economic changes associated with the transition period have had a negative impact on employment, people's social well-being, and the social safety net. All these factors have contributed to a growth in drug use, commercial sex work, and migration. Current data and behavioural and social trends indicate a very high potential for further growth of the HIV epidemic. Its evolvement could be explosive.

SOCIO - DEMOGRAPHIC PROFILE OF PLHIV

Available data suggest that 18.5% of HIV-positive citizens were infected outside of the country, mainly in Russia and Ukraine, and 4.1% are foreign citizens. At the present time young adults are the most widely affected demographic (27,3% of PLHIV are aged 20-29 and 43,8% are 30-39 years old, (Republic AIDS Center, 2007). About 83% of all officially registered cases are among men. However, these figures do not reflect the real situation, since women and CSWs rarely choose to get tested for HIV or STIs. Out of 203 HIV-positive women, ninety (65.2%) were infected through heterosexual contacts.

Cases of HIV infection have been identified in all administrative regional districts of Azerbaijan; 32,5% out of all PLHIV live in the capital city of Baku (total population around 3 million). Some cities in the south close to the Iranian border, like Lenkaran, have become centers of the epidemic.

HIV SURVEILLANCE

HIV surveillance has been carried out in Azerbaijan since 1987. The testing policy has changed over time and the mandatory testing policy no longer exists, except for blood donors.3 Not surprisingly, the policy change - from mandatory to voluntary testing - has resulted in a considerable drop in the number of HIV tests performed annually. The first sentinel HIV surveillance was conducted in 2003.

Even though anonymous, 24-hour, voluntary HIV consultation and testing has been available in all cities and regions of Azerbaijan since 2002, it has been observed that few people are taking advantage of these services, especially counselling (UNAIDS/WHO, 2004). Everyone tested for STIs at a state clinic is also usually tested for HIV. However, private clinics that provide testing for STIs do not report the results to the state agency - the Republic's Skin and Venereal Diseases Dispensary - which makes it more challenging to control and track HIV and STIs.

SOCIO-ECONOMIC FACTORS

The Great Silk Road passes directly through Azerbaijan, which has a shoreline on the Caspian Sea and whose location, in the eastern part of South Caucasus, has historically made it one of the main transport corridors between Asia and Europe. Rise of substance abuse and commercial sex, a heavy inflow and outflow of people - as well as nearly one million refugees and internally displaced persons (IDPs) - play a key role in how the HIV epidemic is developing. Just one example: thousands of foreign workers are currently in the country temporarily to help build the ETC oil pipeline {Baku, Azerbaijan, Tbilisi, Georgia, and Ceyhan, Turkey and the Baku (Azerbaijan)-Arzurum (Turkey) gas pipeline.

INJECTING DRUG USERS (IDUS)

In contrast to the trend in many other countries (with the exception of Eastern Europe and Central Asia), the primary mode of HIV transmission in Azerbaijan is not unprotected sex, but injecting drug use; 58% of all PLHIV contracted the infection this way.

According to the Republic Drug (Narcology) Dispensary4 drug use has increased substantially in the last fifteen years; drug use prevalence per 100,000 people was just thirteen in 1988, but had risen to 155.1 by 2006. Out of 17,000 drug users officially registered with the Republic Drug Dispensary in 2006, 87% were injecting drug users; 34% of all registered IDUs reside in the capital. Therefore, it is thought that the real number of drug users in Azerbaijan is even higher (UNAIDS/WHO, 2004).

Azerbaijan's proximity to major drug trafficking routes, including Afghanistan-lran-Russia and I ran-Azerbaijan-Georgia-Europe, has deepened the country's drug problem by facilitating drug consumption. Poor living conditions and dissatisfaction with life, combined with the availably of illegal drugs, have led to an increase in injecting drug use and consequently, a heightened risk of HIV.

Unemployed people - 76% of IDUs are out of work (Abdullayev & Nasibov, 2004) - and young adults - 65% of IDUs are between the ages of 21 and 30 (Kasumov et al., 2003) - from the poorest rural areas tend to have a deep sense of hopelessness and are thus more vulnerable to drug use. Drug use is much lower among women (5%, Abdullayev & Nasibov, 2004) than among men; this is due to strong traditional gender roles as well as the bigger stigma associated with female drug use.

A UNICEF study (2002) showed that 77% of teenagers have never used drugs or other toxic substances while 5% reported using drugs on a regular basis. The highest rates were among street children and children who had come into conflict with the law.

The prevalence of HIV is twelve times higher among the so-called 'street IDUs' than among IDUs who have registered with narcology centres. This indicates that the main part of epidemic remains outside national preventive and care efforts. IDUs who are registered with drug dispensaries tend to maintain regular contact with medical personnel and as a result, have a higher level of awareness about HIV and AIDS.

The public perception of drug use as a crime complicates the efforts to reach out to, work with, and collect comprehensive data from, IDUs. A fear of public disclosure and of being 'officially registered' discourages users from visiting medical facilities and reduces their access to treatment and prevention methods. (In accordance with current legislation, any drug user who enters a medical institution should be tested for HIV.) Despite widespread negative social attitudes towards drug users, families do not often reject a family member who is using drugs, and instead offer them help in an effort to keep them at home.

The Republic and City Drug Dispensaries provide free medical treatment to people dependent on drugs. In 2002, the Republic Drug Dispensary established the Rehabilitation Center and started a methadone programme. Currently two local NGOs - the Scientific-Analytical Centre: AntiNarcotism and the Azerbaijan Association of Public Health, funded by the Open Society Institute/Soros Foundation (OSI) - have been running needle exchange programmes.

However, the implementation of harm reduction programmes is complicated by the current legislation.6 Nevertheless, the existing number of programmes and organizations working on drug and HIV prevention is insufficient to respond for the current levels of drug use. Moreover, most of the programmes are located in Baku, while drug use is more widespread in other regions, mostly rural areas. Psychological support, treatment and social rehabilitation programmes are still not widespread in the country.

SEX WORKERS

Poor economic conditions and a lack of well paid jobs or alternative employment opportunities is undermining the local traditional values and family relations. Desperate conditions have forced an increasing number of people to seek any source of income, including commercial sex work. As sex work is illegal in Azerbaijan, surveying the actual number of CSWs is very difficult and any estimate tends to be inaccurate.

The influx of considerable number of well-paid foreign workers who have arrived in the country as a result of major foreign investments in the oil industry, combined with new economic opportunities and rapidly-changing communities around the pipelines, have created a higher demand for CSWs, particularly in the capital and near remote pipeline worker camps.

Another consequence of the impoverished conditions has been a rise in human trafficking. According to the International Organization on Migration (2002), people who are driven by the desire for a high-salaried job abroad are sometimes deceived into situations where they are trafficked for sexual exploitation. Women from Azerbaijan and certain other former Soviet countries (Russia, Ukraine, and Uzbekistan) are usually trafficked to Turkey and the United Arab Emirates (UAE).

In 2006 the Republic AIDS Center conducted the first sentinel epidemiological and behavioural HIV surveillance survey among 200 CSWs in Baku. The majority of female CSWs (64.5%) were between the ages of 20 and 30 (8.5% were under 20), and primarily from rural areas (only 32% were from Baku). Only one person was married, the rest were divorced (48%), widowed (18%), or had never been married (27%).

Women who do not have a male life partner often experience financial difficulties and come under social pressures that can push them into sex work as a way of making money. Out of the 200 CSWs surveyed, 17 (8.5%) were HIV-positive and 146 (74%) had other STIs - syphilis, 9% and chlamydia, 63%. Between 78-86% of the interviewed CSWs did not use condoms, and none of the seventeen who were HIV-positive had used a condom during their last sexual contact. Among the main reasons they cited for not using a condom was that the client had refused to wear one, or they themselves had simply not thought 'there was a need.'

There are almost no educational programmes (including on HIV prevention) in Azerbaijan aimed at CSWs or their clients. In addition to sex work being illegal, CSWs are severely stigmatized and rejected by their families and communities and as a result, have a very thin network of social support. Often, CSWs are deprived of their rights, have limited access to medical services - including prevention and timely treatment of STIs, including HIV - and are rarely granted the right by their clients to negotiate safe sex.

MEN WHO HAVE SEX WITH MEN (MSM)

One per cent (1,1%) of the total number of registered PLHIV are men who have sex with men (MSM) (Republic AIDS Center, press release 2007). Sexual relationships between people of the same sex are no longer against the law (since 1999) in Azerbaijan, but MSM are one of the most stigmatized population groups, and public admittance of one's homosexuality is not common. Because of this, there is almost no reliable sociological and epidemiological data available on this group.

YOUTH

As previously stated, youth are one of the most HIV-vulnerable populations in Azerbaijan. Teenagers have some of the lowest rates of HIV infection - just 2% of out all PLHV (Republic AIDS Center, 2007), but people aged 20-30, who lead more independent lives away from their families and are more sexually active, comprise one third (21.3%) of all PLHIV and represent the most urgent priority for HIV/AIDS prevention, treatment, support and care programmes. In the current difficult social circumstances, many young adults assume responsibly for supporting their parents and/or families and are under tremendous economic and social pressure, which makes them more vulnerable to drug use, labor migration, and commercial sex work. Young people aged 20-30 - especially those with a low level of education and thus, fewer employment opportunities - are strongly represented among key populations (65.5% among IDUs, 64.5% among CSWs, and a high prevalence among migrants although no exact figures are available.

Today's Azerbaijani youth is quite heterogeneous: there are several sub-cultural groups whose values, personal interests, and lifestyles vary greatly. Consequently, within each group the type and frequency of high-risk behavior varies.

Most youth in Azerbaijan have been raised in traditional families and grown up in a quite conservative social environment. Their behavior is controlled by family members and other social institutions (neighbors, public opinion, etc); parents consider this method to be the only effective way to protect their children from socially-unacceptable behaviors. But these parents may not be aware that raising their children in such a strict environment may also leave them unprepared to face difficult decisions or resist peer pressure (especially on issues of sexuality and drug use).

Moreover, young people may hold strong prejudices and stereotypes against people who are infected and/or affected by HIV and AIDS, which can perpetuate their lack of awareness of and recognizing behavior that may put them at risk to HIV.

In contrast, a smaller group of young people living in the more tolerant and liberal environment of Baku appear to be more accepting of changing social norms and behaviors. Members of the older generation often criticize their behavior and believe that their less conservative lifestyle and personal relationship habits (e.g. premarital sexual contact) may increase their risk to HIV. In reality, however, fewer prejudices encourage openness to knowledge about HIV and AIDS, which in turn may reduce the risk of infection.