The European Journal of Public Health Advance Access originally published online on June 24, 2005
The European Journal of Public Health 2005 15(4):336-338; doi:10.1093/eurpub/cki003
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Infectious Diseases |
On the European Union's new eastern border: health promotion, HIV and Ukraine
Lindsay Neil1, Oleg Zalata2 and Richard Coker3
1 The Old House, Bredwardine, Herefordshire HR BY, UK
2 Republican AIDS Centre, Simferopol, Autonomous Republic Crimea, UK
3 ECOHOST, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
Correspondence: Dr R. Coker, Senior Lecturer, ECOHOST, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK, tel. +44 207 927 2926, Email: richard.coker{at}lshtm.ac.uk
Received September 11, 2003, accepted March 25, 2004
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Abstract |
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HIV control in Ukraine is a pressing public health challenge and national efforts to control the epidemic have been hindered by a lack of capacity and resources. One component of control is the need to raise awareness. Implementing a health promotion strategy through the education system and through multi-sector network with early stakeholder ownership resulted in a limited budget being spent principally on production costs rather than purchasing media time and space with considerable savings. Early involvement of powerful corporate stakeholders in multi-disciplinary teams has the potential to enhance the effectiveness and efficiency of health promotion measures in a post-Soviet transitional economy.
Keywords: Ukraine, HIV, healthy promotion
In April 2004, the borders of the European Union will be redrawn and the countries to the east will include Russia, Belarus and Ukraine. Some have questioned the epidemiological trajectory of HIV in Ukraine and suggested that the epidemic peaked in 1997.1 Others, however, have drawn attention to the validity of official notification data, and argued that the likely situation is that Ukraine is witnessing a major epidemic of HIV which is partly obscured through frail surveillance systems.2 The epidemic is being driven, as in other parts of the former Soviet Union, by behavioural changes consequent upon seismic socio-economic changes that have occurred over the past decade.
Officials in Ukraine recognize the frailties of their system. Indeed, official policy is framed not only by surveillance data but also by independent research which has been formative in driving the policy agenda and informing the national plan.3 As in Russia, this epidemic was initially associated predominantly with high rates of transmission in injecting drug users and is now, as it matures, affecting other marginalized groups including commercial sex workers and, perhaps more recently, affecting other less vulnerable populations (exemplified by, for example, increases in prevalence among pregnant women).4 Recently gathered data show that the proportion of individuals who acquired their HIV sexually is increasing in regions affected early in the epidemic (Oleg Zalata, unpublished results).
National efforts to control the epidemic are challenged by a lack of capacity and resources.5 Widespread access to highly active anti retroviral therapy (HAART) treatment is beyond both the public purse and almost all private incomes. Moreover, infrastructural capacity and skills in prevention and treatment of opportunistic infections associated with HIV disease are underdeveloped. As the epidemic matures and the cohort of those already infected becomes more immunocompromised the collision of this epidemic with the epidemic of tuberculosis (and multidrug-resistant tuberculosis) is likely to be devastating in coming years.6
The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) agreed in April 2002 to support HIV control efforts in Ukraine by promising approximately $90 million over the next 5 years (although the first disbursements have become available only recently because of infrastructural frailties). In addition, the World Bank is currently in an advanced stage of negotiation with the Ministry of Health with respect to a loan of $60 million to further bolster HIV and tuberculosis control efforts. The effects of these new sources of support will, however, take time to make an impact given infrastructural capacity weaknesses, fragmented lines of accountability and a lack of integration between HIV programmes and other programmes such as those tackling tuberculosis. In the meantime, awareness of needed behavioural changes to reduce the risk of transmission amongst groups at high risk of acquiring HIV and the wider general public remains low.7,8 Effective and efficient health promotion models are clearly needed to prevent spread within those populations participating in high risk activities (such as injecting drug users who share needles), as well as populations linked through sexual networks. Moreover, if communication strategies are to be effective in supporting behavioural change, they need, amongst other characteristics, to address the specific nature of the challenge countries face, including geographical, cultural and epidemiological features. The evidence base to support health promotion practices is often context-specific and many models would not cross cultures.9 Whilst external financial support through international agencies seems substantial in Ukraine, only a small proportion of these funds is dedicated to health promotion, the country is vast, the population widely dispersed, heterogeneous and accessible largely only through mainstream media.
In response to the need to increase awareness of HIV the European Commission funded a project to increase awareness of HIV in six demonstration regions (Dontesk, Kharkiv, Lviv, Kherson, Sevastopol and the Autonomous Republic of Crimea). With a budget of 
1.9 million the challenge was to maximize impact through securing the commitment and resources of multiple actors and agencies, and provide illustrative models that larger-scale health promotion efforts might effectively and efficiently replicate.
To respond to this challenge, local strategic planning was supported by European Commission-funded technical experts, action plans were drafted by local actors and implementation was driven locally. Accountability rested with local steering groups; local ownership was ensured.
Implementation rested upon two principle planks. On the first, the education system (including the Ministry of Education, schools, teacher-training programmes, continuing professional development courses) was encouraged to embrace notions of health promotion and use their resources to inform and educate their charges. Such an integrated approach that crossed administrative boundaries had not been conducted before in Ukraine, probably because traditional Soviet administrative structures make such cross-cutting health promotion models difficult to implement.
The second involved a novel network of ministry officials, media representatives, NGOs, British Council and European Commission representatives and internationally recognized celebrities including Elton John. This network, led by the Ministry and media, designed and launched a campaign in the six regions. As with the cross-cutting educational component, this collective model was new to Ukraine. Traditionally, institutional partnerships aimed at promoting health had involved fewer partners and any television advertising space had had to be bought at considerable cost. This approach may also be novel from an international perspective. Many other health promotion models have harnessed the power of television in middle income countries, of course, but these have often either featured government-funded advertisements (such as in much of Western Europe) or incorporation of HIV ‘story-lines’ in ‘soap’ operas.9
The collaboration through this network, including the involvement of senior media partners in the early stages and throughout the project implementation, meant that a limited budget of 90 000 was spent largely on production costs rather than commercial costs of airtime or print space. Table 1 illustrates two examples of the savings made. The estimated cost of procuring these outputs privately would have been substantially greater than the 90 000 total budgetary allocation for the campaign.
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Preliminary analyses of output measures suggest that awareness of HIV routes of transmission increased significantly in those exposed to the campaign through the education system compared to unexposed controls. And the broad media campaign was run through 93 local television channels. Between them, the public service announcements, for example, were put out 3382 times during December 2002 and January 2003.
If Ukraine is to effectively and efficiently control its burgeoning epidemic of HIV then much needs to be done. The lessons that can be drawn from the effective health promotion campaign described briefly here suggest that local capacity and skills can be developed and harnessed to design and implement programmes that are locally ‘owned’ if given sufficient support. Moreover, local stakeholders, including corporate players, can be effective and supportive if involved early in design and seen as partners, not simply as messengers. In adopting this approach, health promotion campaigns such as this can efficient, effective, and at the same time build a cohesive multi-disciplinary response with a shared purpose that might be built upon and harnessed in future campaigns. The success of such initiatives should be of importance to all those concerned about the different trajectories of HIV epidemics either side of the new European Union border if the frequent refrain that infectious disease knows no borders is to be taken to heart.
Key points
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1 Mavrov GI, Bondarenko GM. The evolution of sexually transmitted infections in the Ukraine. Sex Transm Infect 2002;78:219–21.
2 Amon JJ. The HIV/AIDS epidemic in Ukraine: stable or still exploding? Sex Transm Infect 2003;79:263–4.
3 Barnett T, Whiteside A, Khodakevich L, Kruglov Y, Steshenko V. The HIV/AIDS epidemic in Ukraine: its potential social and economic impact. Soc Sci Med 2000;51:1387–403.[Medline]
4 Ministry of Health HIV/AIDS Surveillance in Ukraine (1987–2000) Kyiv, Ukraine, 2000.
5 Ministry of Health. Plan of a national response to HIV/AIDS in Ukraine for 2001–2003. Kyiv, Ukraine, 2000.
6 EuroTB (InVS/KNCV) and the national coordinators for tuberculosis surveillance in the WHO European Region. 2003. Surveillance of tuberculosis in Europe. Report on tuberculosis cases notified in 2000. France: Institute de Veille Sanitaire, Saint-Maurice.
7 Yaremenko A, Balakira O, Artyukh O, et al. Cost-effectiveness analysis: aiding decision-making in HIV prevention in the Ukraine. Kyiv, Ukraine: Ukrainian Institute for Social Research, 2002.
8 CDC. Ukraine Reproductive Health Survey,1999, Final Report. Atlanta, GA: Centers for Disease Control and Prevention, September 2001.
9 UNAIDS. HIV/AIDS and communication for behaviour and social change: programme experiences, examples, and the way forward. Geneva: UNAIDS, June 2001.
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