policy discussions surrounding accessibility in former soviet union (fsu) nations highlight significant challenges. these regions are now recognized as key areas for intervention.
a detailed thematic analysis of qualitative data, conducted by country-specific teams, followed by a comparative synthesis by the authors, illuminated these issues.
common approaches to achieving universal access often presume that an increase in service availability automatically translates to improved accessibility.
however, this perspective overlooks the intricate realities on the ground. the original source material, while referencing specific locations like kurgan-tyube, tajikistan, in its heading, actually delves into a broader regional analysis of hiv prevention and its connection to infrastructure development and population movement.
the research presented here, originating from the asian development bank (adb), offers a critical examination of these complex interdependencies.
the views expressed are those of the authors and do not necessarily represent the official stance of the adb or the governments it serves. this publication is part of the central and west asia department working paper series, a platform designed to foster discussion and gather feedback on ongoing and recently completed research.
the series focuses on development challenges, particularly within the central and west asia subregion, as well as conceptual, analytical, and methodological aspects of social and poverty analysis, and data measurement related to projects and programs.
the evolving landscape of hiv in the central asian region
the former soviet union, particularly its central asian republics, faces substantial hurdles in addressing public health concerns, with hiv being a prominent example.
policymakers have increasingly identified this region as a priority.
the ADB's involvement in rehabilitating key transport routes, such as those under the central asia regional economic cooperation (carec) program, underscores the interconnectedness of infrastructure development and public health outcomes.
three out of the six carec road corridors traverse tajikistan, enhancing connectivity within the country and linking it to neighboring nations and beyond.
the north-south corridor, for instance, connects tajikistan with afghanistan, kazakhstan, and the russian federation. these improved routes are designed to reduce isolation and bolster regional connectivity by linking densely populated areas. this enhanced connectivity extends the reach to the kyrgyz republic, europe, china, southeast asia, india, and pakistan.
following its independence, the five former soviet central asian republics established a common definition of central asia, encompassing kazakhstan and the original four republics designated by the soviet union.
this broadened definition is now widely accepted. the anticipated increase in population movement between the kyrgyz republic and tajikistan, driven by ongoing transport infrastructure development, presents a significant public health challenge.
this growth in transit is not limited to these two countries; increased movement is also expected with kazakhstan and the russian federation, nations where the prevalence of hiv within at-risk populations is notably high.
furthermore, improved connections with afghanistan, a major hub for illicit drug production, introduce another layer of complexity to the region's public health landscape. an additional factor contributing to the risk is the influx of laborers involved in road construction projects.
hiv prevalence and transmission dynamics in kyrgyzstan
the kyrgyz republic was once the last hiv-free nation within the commonwealth of independent states (cis).
however, by 2013, the total number of officially registered people living with hiv (plhiv) had reached 9,112. a particularly concerning trend observed in the kyrgyz republic since 2011 has been a sharp increase in hiv cases among women, with women comprising 9.7% of registered cases in that year.
a 2013 report indicated that the highest proportion of registered hiv cases in the kyrgyz republic was concentrated in specific regions, with statistics like "6 maichiev, hiv in kyrgyzstan" pointing to localized data. it's important to distinguish between registered cases (officially reported and documented in health facilities) and estimated numbers, which are derived from surveys.
hepatitis c prevalence was also high among injecting drug users in the kyrgyz republic in 2013, standing at 38.1%.
crucially, the same practices that facilitate the spread of hepatitis c - namely, the sharing of needles and the use of contaminated blood for transfusions - are also significant contributors to hiv transmission.
according to the united nations development programme (undp), the primary transport corridors in the kyrgyz republic are also major conduits for drug trafficking.
these routes connect the country to afghanistan and other nations with a high prevalence of hiv, such as kazakhstan and the russian federation. the escalating volume of drug storage and transit along these pathways is directly linked to an increase in hiv-positive injecting drug users.
data from 2013 reveal that half of all registered hiv cases in the kyrgyz republic were located in osh city and osh oblast, both critical transport hubs.
cities that serve as key transit points and have substantial populations of injecting drug users and sex workers, including khujand, tursunzoda, kulob, kurgan-tube, khorog, and faizabad, all lie along these major transport corridors. in these areas, hiv prevalence rates are nearing levels associated with concentrated epidemics.
tajikistan's hiv situation and vulnerabilities
similarly, in tajikistan, the hiv prevalence rate was recorded at a low 0.2% in 2013.
however, widespread low awareness of hiv transmission, engagement in risky behaviors, and limited knowledge of protective measures render the entire tajik population vulnerable to the epidemic. the ongoing improvements to transport corridors, while beneficial for economic development, are predicted to exacerbate the risk of an hiv epidemic by facilitating greater movement of people and goods both within and across national borders.
understanding key populations and risk factors
key populations in all countries at risk of hiv include individuals living with hiv.
however, certain groups face a disproportionately higher risk of hiv exposure. these typically include men who have sex with men (msm), transgender individuals, people who inject drugs (pwid), sex workers and their clients, and seronegative partners in serodiscordant couples. these groups are inherently more vulnerable than the general population.
in tajikistan, the number of registered sex workers saw an increase from 8,967 in 2011 to 12,560 in 2013.
the clients of these sex workers often belong to mobile demographic groups, such as traders, taxi drivers, and migrant laborers who travel extensively along major transport corridors. even if a smaller proportion of these clients are infected, their mobility significantly increases their potential to transmit the virus to a wider network of individuals.
in the kyrgyz republic, approximately 6,000 sex workers were estimated in 2013, with a significant concentration in Bishkek (1,500) and Osh City (900), followed by Jalalabad.
studies have indicated that a substantial percentage of these individuals engage in high-risk sexual behaviors. for example, a 2013 study found that 4.9% of female sex workers tested positive for hiv. mobile populations, such as migrant workers, are particularly at risk. often absent from their homes for extended periods, they are more likely to engage in behaviors like having multiple sexual partners, participating in commercial sex, and injecting drugs.
migrant workers in tajikistan frequently lack adequate knowledge regarding hiv transmission routes, safe sex practices, and fundamental reproductive health.
this combination of limited awareness and risky behaviors positions migrant workers as a highly vulnerable population, with the potential to transmit hiv to their partners, particularly their wives.
intergenerational and partner transmission risks
data from 2013 confirmed that women represented a significant portion of new hiv infections.
in 2013, hiv-infected pregnant women accounted for 2.9% of all reported cases. this poses a risk of mother-to-child transmission (mtct), where infected mothers can pass the virus to their babies during pregnancy, childbirth, or breastfeeding. the increase in sexually transmitted hiv infections in tajikistan, from 38% in 2009 to 50% in 2013, further highlights the growing concern over sexual transmission pathways.
voluntary testing and counseling (vct) services for hiv were available through both government facilities and a considerable number of private institutions.
however, many individuals expressed apprehension about disclosing their hiv-positive status due to fear of social stigma and discrimination from family and community members.tajikistan established a national hiv committee, chaired by the deputy prime minister, with a permanent secretariat and dedicated budget.
this committee was tasked with implementing preventive and curative policies across various ministries and government agencies. international donors, including the world bank, unaids, usaid, the department for international development (dfid) of the united kingdom, the aids foundation east-west, and the soros foundation, provided crucial technical and financial support.
in 2011, special legislation was enacted to safeguard the rights of plhiv and ensure access to free healthcare and social support services. this period also saw an increase in testing among pregnant women and migrant workers.
despite these efforts, the rising prevalence of hiv in higher-risk populations within both the kyrgyz republic and tajikistan, especially among injecting drug users and sex workers, remains a significant concern.
the increased connectivity brought about by improved transport corridors and large-scale cross-border labor migration exposes these countries to neighboring cis nations with higher hiv infection rates.
a regional approach to hiv prevention
the interconnected nature of the hiv epidemic necessitates a regional perspective.
effective hiv interventions require not only robust national strategies but also a coordinated regional approach that encompasses neighboring countries facing similar challenges. the central asia regional economic cooperation (carec) program offers a potential platform for developing an integrated, intersectoral regional strategy to curb the spread of hiv.
within the kyrgyz republic and tajikistan, hiv prevention and control efforts must strategically target the main transport corridors and the urban centers situated along them.
this can be achieved through several key measures:
- developing comprehensive guidelines for identifying and targeting high-risk populations (such as injecting drug users, migrant workers, and sex workers) and high-risk areas (including workplaces and concentrations of migrant households).
- mapping the distribution of these vulnerable populations along the transport corridors to inform targeted interventions.
- strengthening the monitoring and surveillance systems for high-risk groups operating within and along these transport networks.
- building the capacity of governments, national organizations, and international agencies in hiv prevention and harm reduction strategies.
- engaging religious leaders, community influencers, and the mass media to raise awareness and reduce stigma.
- facilitating the sharing of knowledge and best practices, and providing practical training through specialized institutions within the region and in neighboring countries.
the provided references highlight the extensive research and initiatives undertaken by various organizations, including the asian development bank, the united nations development programme, and numerous international NGOs, in understanding and addressing the complex interplay between infrastructure, migration, and hiv vulnerability in central asia.
this underscores the multifaceted approach required to tackle the epidemic effectively.