Margaret Babayan

Danuta Kasprzyk
Honors 391 A
May 29
th
, 2012
Zero HIV/AIDS Cases by 2015:
Goal Report for the Republic of Armenia
Armenia was not yet a completely sovereign nation when HIV/AIDS first permeated the
international consciousness. However, despite its status as a transitioning state, Armenia has
already mobilized in the global fight against AIDS with its own National Programme on
HIV/AIDS. Though promising, the existence of a national prevention platform and a low overall
HIV/AIDS prevalence rate does not make the Armenian populous immune to new infections. On
the contrary, Armenia is far from zero infections, and its location in the Southern Caucasus
makes it highly susceptible to a second wave reemergence of HIV across Eastern Europe.
While it is unlikely that Armenia can halt the transmission of HIV by 2015 given high rates of
migration, injection drug use, and economic instability, the National Programme (NP) has
created an infrastructure that may save Armenian citizens from falling victim to the second wave
reemergence of HIV.
Epidemiology:
An estimated 2500 HIV-infected individuals reside within Armenia and the national
prevalence for people living with HIV/AIDS aged 14 49 is 0.17%, but such a low prevalence
figure should by no means be interpreted as an indication that HIV/AIDS in Armenia is under
control, and the rising prevalence of HIV infections among certain risk populations further
illustrates the countrys vulnerability (UNGASS, 2012, 11). A total of 1153 HIV/AIDS cases and
265 deaths have been registered since the creation of a national surveillance system in 1988
(UNGASS, 2012, 4). Though Armenian health officials first implemented a national registry for
HIV/AIDS fourteen years ago, over half of newly reported HIV/AIDS cases were registered
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within the past four years. In 2011 alone, 182 new HIV cases, 94 AIDS cases, and 46 deaths
from HIV/AIDS were registered (UNGASS, 2012, 5). Such a trend can either signify an unusual
spike in incidence of HIV or, and more likely, that previous HIV/AIDS cases were hidden
among citizens, undiagnosed and unregistered in an ever-apparent prevention cascade. The
likelihood of underreporting in Armenia is high and simultaneously presents a significant barrier
to effective HIV control. Nevertheless, analyzing major routes of transmission as well as
identifying the populations most at risk of infection can help remediate gaps in reporting to
ultimately encourage better data collection.
Identifying the primary modes of HIV transmission in Armenia is a necessary step in
creating high impact programs and controlling the epidemic. Although, acquisition of HIV
through injection drug use was once the prevailing mode of transmission, the majority of new
HIV infections, more specifically 54.3%, are now acquired through heterosexual contact
(UNGASS, 2012, 5). While women are far from equal rights in Armenia and domestic violence
is common within families, the gender imbalance of HIV falls upon males. Among the 182 new
registered cases in 2011, 70.5% were male while only 29.5% were female (UNGASS, 2012, 5).
An alarming majority, or 74.4%, of registered HIV-infected individuals are between the ages of
20 and 39 years old (NCAP, Action Plan, 1). Moreover, 40.6% of registered cases originated
from Yerevan, Armenias capital, and the epidemic is primarily urban (UNGASS, 2012, 7).
Transmission through homosexual contact occurred in 1.7% of registered cases, and the method
of acquisition of HIV in 5% of registered cases remains unknown (UNGASS, 2012, 5). While
mother to child transmission accounts for 1.7% of registered cases and transmission through
blood for only 0.3%, improvements to health systems can further reduce the clinical incidence to
zero, and greater resources should be allocated to combat HIV among risk populations with
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higher prevalence rates (UNGASS, 2012, 4).
The prevalence of HIV among FSWs, MSMs, and prisoners is 1.20%, 2.30%, 1.15%,
respectively (UNGASS, 2012, 9-10). Of all risk groups, however, injection drug users (IDUs), or
people who inject drugs (PWIDs), are most acutely impacted by HIV with a prevalence of 6.5%
reported in 2010 and 2011 (UNGASS, 2012, 12). While injecting drug use was previously to
blame for the majority of transmission, 37.0% of new HIV infections from 2010 - 2011 occurred
as a direct result of injecting drugs, and although no longer the main mode of transmission,
reducing transmission through injection drugs is critical in consequently reducing heterosexual
transmissions (UNGASS, 2012, 5). The HIV epidemic in Armenia is clustered among young,
urban men who more likely than not, are also injection drug users. Individuals infected through
sexual contact who abstained from drug use were most likely infected by partners who actively
engaged in the practice: less than 50% of IDUs used a condom during their last sexual encounter
thus indicating that educational and behavioral interventions are needed, especially as
heterosexual transmission becomes increasingly prevalent (Kvitsinadze, 2010, 30). High
transmission rates associated with injection drug use coupled with the low prevalence of condom
use among IDUs may react synergistically to produce increased HIV infections among
heterosexual couples. Thus, special attention should be paid identifying cases and treating
individuals with HIV/AIDS who are also IDUs as well as disseminating valuable knowledge
among IDU populations.
Treatment Coverage, Goals, and Costs:
In November of 1989, the National Center for AIDS Prevention (NCAP) of the Ministry
of Health of the Republic of Armenia was created to coordinate and implement HIV/AIDS-
related activities, and acts as the lynchpin between NGOs, IGOs, the private sector, the Ministry
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of Health, and foreign governments. While acting as a liaison, NCAP simultaneously runs its
own prevention and treatment services including, but not limited to: national research and
surveillance; testing and diagnosis; providing ART and treating opportunistic illnesses for all
qualified individuals; creating and disseminating educational materials; and training healthcare
practitioners (NCAP, 2012). With assistance from UNAIDS/UNDP and the GFATM, the NCAP
developed the NP for 2007 2011 on HIV Prevention, Armenias centralized response to HIV
(NCAP, 2012). Divided into six broad strategy areas, the NP aims to foster: the development of a
multisectoral response to HIV; HIV prevention; treatment, care, and support; monitoring and
evaluation; management coordination and partnership; and financing and financial resources
mobilization (NCAP, National Programme, 3).
Treatment, care, and support is a section within the framework of the National
Programme and its sole objective was to by 2011 ensure universal access to treatment, care, and
support
1
(NCAP, National Programme, 11). Rather than constructing new infrastructure, the
NP laid the foundation for the integration of HIV/AIDS treatment into Armenias present health
system by creating programs to train professionals and provide facilities with resources for
diagnosis and care. In 2005, well before the development of the NP, provisions granting free
ART and follow-up care including blood testing and psychological support to all HIV-infected
individuals in need were established by law (UNGASS, 2012, 14). By legally prioritizing ART
and opportunistic illness treatment as well as increasing the efficiency of treatment within
healthcare systems, the Ministry of Health hoped that 100% of identified HIV-infected
individuals had access to ART, opportunistic illness treatment, and counseling, and that all health
care facilities would have access to the means of providing such care to patients (NCAP,

1
Note: The National Programme is divided into six broad areas and has identified multiple key objectives within
each area.
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National Programme, 12). However, it is clear that 100% access is not the same as 100%
coverage. Currently, 555 adults and children living with HIV are enrolled in HIV care
(UNGASS, 2012, 11). Of all registered cases, 330 adults and children living with HIV were
receiving ART in 2011, and 84% of those receiving treatment were still on treatment 12 months
after initiating ART (UNGASS, 2012, 10). More alarmingly, 18 per 100 IDUs living with HIV
were receiving ART in 2009 (Mathers et al, 2010, 1017). A lack of sufficient funding may
explain the inability of the Ministry of Health to provide treatment to everyone, but the disparity
between treatment rates among the generalized population and injection drug users indicates that
perhaps certain populations are being systematically marginalized from care. Non-governmental
organizations are present in Armenia, and attempt to coordinate treatment activities, but those
that provide biomedical treatments are often linked to and managed by the Ministry of Health
and the NCAP (Markosyan et al, 2006, 140). Instead, psychosocial support for people living with
AIDS (PLWA) has been the focal point of many HIV/AIDS-related NGOs, but discrimination
exists even among NGOs, and not all subgroups of PLWA are reached through NGO efforts
(Markosyan et al, 2006, 141).
The Ministry of Health projected treatment activities under the National Programme to
cost a total of AMD 3.6 billion (USD 9.2 million) with 47% of treatment costs covered by the
state budget, and the remainder flowing from outside sources such as the Global Fund and
private donors (NCAP, Financial Resources, 38). The largest portion, AMD 1.5 billion (USD 3.8
million) or 41% of treatment dollars, was allocated for the continuous provision of ARV to all
those in need (NCAP, Financial Resources, 34). While total spending for ART has increased
from 2008, spending on ART dropped from USD 1,420 per person in 2008 to USD 869 per
person in 2009, likely as a result of decreased international resources earmarked for ART as well
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as the increased number of patients needing treatment (UNAIDS, 2012). Treatment-specific
activities were projected to therefore cost Armenias state less than 0.05% of its GNP (World
Bank, 2012).
Prevention:
The National Programme outlines HIV prevention goals in Armenia by classifying
prevention activities with regard to key populations, those being: IDUs, CSWs, MSMs,
prisoners, migrants, EVYP and MARA
2
, adolescents aged 15 24, infected pregnant women,
and uniformed personnel (NP PDF). Prevention of HIV within Armenia is primarily coordinated
through the Ministry of Health, but nongovernmental organizations may bypass the NCAP and
the NP to conduct their own activities. The NP prioritizes behavioral education as well as
voluntary testing and counseling (VTC) to reduce HIV transmission among all identified groups,
and aims to reach at least 75% of individuals within risk groups
3
through the development of
such programs (NCAP, National Programme, 5-10). After presenting knowledge of HIV
prevention techniques to risk groups, the NP hoped to have impact results as high as 95%
condom use among risk IDUs, MSMs, and CSWs, as well as 75% condom use among migrants
(NCAP, National Programme, 7-10). The NCAP planned to distribute over a million condoms
among risk populations from 2007-2011 in addition to educating populations about proper use to
ensure that knowledge would manifest itself in action (NCAP, Monitoring and Evaluation
Indicators, 40). The creation and implementation of harm reduction programs for IDUs through
substitution therapy as part of the NP was meant to further reduce new infections through
injection drug use. Inherent stigmas associated with both HIV and belonging to risk populations
are also addressed in the NP, and emphasis is placed on drafting programs that reduce stigma by

2
Especially Vulnerable Young People and Most at Risk Adolescents
3
Note: target coverage percentages vary given risk group
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educating as well as empowering vulnerable individuals like CSWs and including them in the
implementation of prevention activities (NCAP, National Programme, 9).
Although treatment is not addressed as a prevention technique specifically, the NP goes
beyond targeting risk populations through educational and behavioral change programs to
prevent HIV transmission by identifying and implementing structural changes needed to
strengthen the national response to HIV through biomedical advances. The establishment of
laboratory centers to run HIV tests in Yerevan is but a first step to ensuring all donated blood is
tested and that VCT services can exist. Moreover, the NP stresses the integration of HIV into the
national medical system by providing both materials and training to health practitioners and
officials (NCAP, National Programme, 10). Emphasis is placed on promoting sanitary clinical
conditions and ensuring universal access to PEP within all facilities to enable 100% coverage
and extinguish any occupational HIV infections. Prevention activities under the NP were
projected to cost AMD 5.9 billion (USD 14.6 million), with roughly 22% of funds originating
from the states budget, and the remainder stemming from international nonprofits as well as
private sources (NCAP, Financial Resources, 38).
While HIV prevention activities under the National Programme are planned and
administered through the Ministry of Health, NGOs and IGOs facilitate HIV prevention
independently as well. Most notably, the Open Society Institute, a private nonprofit centered on
improving social justice throughout Europe, runs the Open Society Institute Armenia Foundation
(OSIAF) Armenia Public Health Program which advocates for the creation of socially sound
legislation as well as runs its own harm reduction programs (Open Societies Institute, 2012).
Needle exchanges, for example, though not addressed by the NP exist as a result of OSIAF
funding and implementation. The Armenian Red Cross, too, trains volunteers to educate
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community members about HIV, and disseminates surprise boxes containing HIV educational
materials to the general public (International Federation for Red Cross, 2012, 9). Such activities
are not performed through the Ministry of Health, but contribute to HIV prevention efforts in
Armenia. Unfortunately, impact analyses do not exist for these activities, they are sporadically
distributed, and the coordination of prevention activities should ultimately be left entirely to the
Ministry of Health and NCAP, especially when funding is centrally coordinated.
Political Climate and Commitments for Funding:
The fall of the Soviet Empire granted Armenia long-awaited independence, but also sent
the country into a downward economic spiral as a transitioning state thus confounding existent
structural problems. Moreover, economic development within Armenia has been stifled by frigid
relations with Azerbaijan and Turkey as a consequence of the Nagorno-Karabakh Conflict
4
and
Turkeys refusal to recognize the Armenian Genocide. Such tension in the Southern Caucasus
presents inherent challenges to both Armenian economic development as well as HIV treatment,
prevention, and control efforts. Presently, 35.8% of the Armenian populous dwells in poverty,
and individuals pay most healthcare expenses out of pocket (World Bank, 2012). Therefore, the
provision of free or low cost services is necessary for the NPs services to reach target
populations; however, a free or low-cost service scheme requires immense funding. Given
Armenias status as a low middle income country, the creation and very existence of the NCAP
and the NP stemmed from international funding, and such funding must be sustainable.
The Ministry of Health, the Ministry of Finance and Economy, and the Country
Coordinating Commission of HIV/AIDS, Tuberculosis, and Malaria issues (CCM) secure and

4
Nagorno-Karabakh is a war-torn region that falls within the borders of Azerbaijan, but was historically occupied
by ethnic Armenians. The violence itself stems from the presence of both Armenian and Azeri citizens within the
region, and the disagreement over whether Armenia or Azerbaijan should gain jurisdiction. Racially-charged
violence escalated into an armed conflict. Though a cease-fire was signed in 1994, violence and intense political
stagnation is still present.
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allocate funding for the NP. To ensure the security of funds for its own implementation, the NP
itself established a National Conference of Donors and aims to develop civil society capacity for
fundraising and coordinating mechanisms to ensure that activities are not duplicated (NCAP,
Action Plan, 21). Upon the creation of the NP, Armenian officials hoped that the state would
provide at least 35% of the Programmes necessary funding (NCAP, National Programme, 4).
However, of the USD 2.3 million spent on HIV programs in 2009 alone (much less than the
expected cost), USD 1.7 million was paid for by international sources (UNAIDS, 2012).
Furthermore, the Global Fund to fight AIDS, Tuberculosis and Malaria is not only the very
raison d'tre
5
of the NP, but also provided USD 1.2 million, or 70% of all international aid, to
fund activities in 2009 (UNAIDS, 2012). The Global Fund has approved a total of USD 35.3
million for HIV/AIDS spending in Armenia through the CCM (Grant Portfolio Armenia,
2012). Thus, international aid, more specifically, monetary support from the Global Fund will
remain fundamental to the continuation of future HIV/AIDS prevention and treatment efforts
within Armenia until economic change that will enable Armenia to fund the NP on its own
occurs.
Gaps in Epidemiology:
Given present stigmas, the criminalization of activities characteristic of risk groups, and
the mobile nature of migration, data regarding HIV in Armenia is not accurate and most likely
underrepresents the extent of the HIV epidemic within sub populations. Epidemiological data is
constructed within the constraints of the socioeconomic schemes and forces governing any
society. Indeed, one of the most cumbersome aspects of HIV prevention, control, and treatment
in Armenia is inaccurate surveillance data due to the undercoverage of stigmatized risk

5
Reason for existence
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populations in reporting caused by inequality as well as the prevalence of conservative
sociocultural norms. The unprecedented number of HIV cases registered within the past couple
years indicates that more HIV tests are being done as a result of augmented efforts, particularly
in urban settings such as Yerevan where state of the art testing centers have been established.
Increased voluntary testing among non-IDU individuals can be attributed to the integration of
HIV testing in STI clinics, the adoption of rapid testing, and the establishment of regional testing
centers in all marzes
6
(Buckley, 2008, 13). However, increased testing availability and coverage
among the general population may not (and does not) guarantee an accurate description of the
epidemic. The mandatory testing of expectant mothers and screening of all blood is a significant
step in HIV control which helps identify new cases and prevents new infections from occurring,
but such testing inherently excludes high-prevalence groups that are the most at risk. IDU, MSM
and CSW sub-populations are marred by stigma, and while the availability of testing is now
more widespread because testing centers are now present outside of Yerevan, self-identification
within one of these groups, especially within a national registry, is unwelcome. While the NP
aims to alleviate such stigma through educational interventions, sex work and drug use are both
still criminalized, and individuals believe that candid discourse with government
representatives will result in punishment or social exclusion (Markosyan et al, 2006 141).
Homosexuality, too, though decriminalized in the 1990s after the lifting of Soviet bans, remains
condemned in a highly religious state. Therefore, data collection must go beyond the national
registry to capture the true extent of the HIV epidemic within Armenia for resources to be
allocated accordingly. Sentinel testing within sub populations is critical, but because it is not
randomized, there is risk of following networks through one node and either overestimating or
underestimating prevalence and transmission rates (Buckley, 2008, 21). The NCAP found

6
administrative districts
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through sentinel tests that prevalence was 18.52%, 7.5% and 0.9% in 2006 among IDUs, CSWs
and MSMs, respectively (Buckley, 2008, 20). There is an overt discrepancy between sentinel
reports and data collected through the national registry, indicating that present data is not
sufficient because populations are not being reached.
Record keeping of transmission rates is flawed as well because stigmas are present even
when subpopulations are reached, and the adoption of better testing methods will not guarantee
accurate data regarding transmission. One intake counselor from a testing center in Baku
admitted that he could identify an MSM, and declined to read that option to Azeri men on the
intake form because Azeri men would not commit such deeds (Buckley, 2008, 17). Another
counselor self-identified IDUs rather than forcing them to admit to shame and conceded that
women were never IDUs, so he declined to identify any woman as such (Buckley, 2008, 17).
Although these instances were documented in Azerbaijan, similar sentiments are reinforced
throughout the Southern Caucasus, and Armenia is not exempt. Such discrimination inherently
skews data collected regarding incidence, prevalence, and transmission rates among risk groups.
Moreover, under the current system of classification, there is no way to tell if an individual falls
within multiple categories, nor which category will be reported to the national registry; this
complicates the process of resource allocation. Therefore, training should be provided to intake
officers in testing centers in Armenia to ensure a universal, anonymous, and nondiscriminatory
system is used to collect surveillance data.
Stigmas about sub-populations and the criminalization of activities that take place within
them are problematic when attempting to construct an accurate snapshot of the Armenian HIV
epidemic, however, the largest barrier to obtaining accurate HIV/AIDS data stems from the
frequency of migration, both legal and illegal, across Armenias borders. Over one quarter of
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Armenians left the country in the 1990s, and 60% of those who left were young men (20-44
years old); such trends are upheld today and are correlated with figures regarding HIV infections
(IOM, 2008, 12). However, prevalence data among migrant populations does not currently exist
and skews the perception of the epidemic in Armenia; more specifically, the lack of data
collection among migrant populations underplays the extent of the epidemic within Armenia.
While the NP calls for the establishment of check-points to test migrants, not all migration is
legal (and cases will therefore remain undetected) and it is unclear whether this plan has been
implemented. Regardless, the collection of accurate data is but a first step in taming the
Armenian HIV/AIDs epidemic. Even if every HIV positive individual is identified, the same
forces that impede on complete data collection are also active in treatment, and it is likely that
not all individuals are receiving the care guaranteed by the NP.
Gaps in Treatment Coverage, Goals, and Costs:
The National Programme is a stunning manifestation of political will to combat
HIV/AIDS within Armenia, and while the Programmes treatment plan is rather comprehensive,
there is no data to indicate whether the goals of the NP have been met. The Programmes
implementation was to span from 2007 through 2011certainly not enough time to analyze its
impact on treatment coverage. An updated NP spanning 2012-2016 has not yet been released
with evidence-based conclusions about the implementation and impact of the 2007-2011 NP.
Monitoring and evaluation reports are useful, but goals, not realistic outcomes, are
communicated through such progression plans.
Further complicating the analysis of the impact and extent of treatment coverage in
Armenia, the very definition of treatment is loosely defined in by the NP, and UNGASS
indicators do not explain the criteria used to determine whether an individual was documented as
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receiving treatment, the effectiveness of treatment, nor the percentage of individuals within
populations that received treatment and care. While 80% of those diagnosed with HIV are treated
according to new WHO guidelines, the figure remains ambiguous, and the best practices for
improving specific treatment access remain unknown (United Nations in Armenia, 2012).
Therefore, the true extent of treatment coverage and its impact as a direct outcome of the
creation and implementation of the NP in Armenia is widely unknown, but UNGASS indicators
cited earlier, such as the disparity in treatment rates between IDUs and the general population,
prove that individuals in need of care, especially those in the highest risk groups, are not
receiving it to the fullest extent possible. Although only 21% of health facilities are equipped to
treat HIV, zero clinics providing ART reported an outage of antiretroviral drugs in 2010 - 2011,
indicating that at the very least clinics which are reached under the NP are covered
comprehensively (UNGASS, 2012, 10). Nevertheless, gaps clearly exist in both the collection of
data regarding treatment as well as the treatment coverage itself. If one is guided by the
paradigm that treatment is prevention (which very well should be the case), then Armenia is
not responding effectively to the HIV epidemic, especially for populations most at risk.
Gaps in Prevention:
On paper, the National Programme outlines an optimistically-framed and extensive plan
to prevent HIV transmission, but the specificity of prevention activities carried out under the NP
as well as their effectiveness and impact among the general population and within individual risk
groups is unknown. Firstly, evidence suggests that activities described under the NP are not
being carried out to their fullest extent. For example, only 40.54% of known HIV-positive
women receive ART to reduce the risk of mother to child transmission during birth and though
no new cases have arisen as a result of mother to child transmission since 2007, there is still
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cause for concern (UNGASS, 2012, 10). Moreover, prevention campaigns are vaguely defined
by the NP. The methodology behind the implementation of educational programs among risk
populations that advocate for behavioral change as well as overall increased knowledge is
undisclosed. However, recently-collected data surveying general behavior among risk groups
does exist and can be used as indicators in analyzing the impact of the NP. Alarmingly, 20.3% of
young men and women aged 15-24 both correctly identified ways of preventing sexual
transmission of HIV and reject major misconceptions about HIV/AIDS (UNGASS, 2012, 8).
Moreover, 16.1% of PWID, 48.4% of MSM and 15.9% of CSWs have had an HIV test in the
past 12 months and know their results (UNGASS, 2012, 10). In addition, 92.9% of CSWs, 65.9%
of MSM, and 43.7% of IDUs reported condom use at their last sexual encounter (UNGASS,
2012, 9). Ultimately, prevention efforts under the NP, while not 100% effective, have at the very
least increased the proportion of individuals within risk groups using condoms and getting HIV
tests, but such a low national knowledge level of HIV indicates that preventative educational
measures are not spanning as far as necessary to stampede the transmission of HIV/AIDS within
Armenia. Indeed, myths such as AIDS is only a homosexual disease and there is a cure for
AIDS still persist in Armenia among college-aged students, and even though the proportion of
students believing such myths has been reduced since 2004, educational efforts should focus on
increasing awareness of sexual health as well as HIV itself (Babikian et al, 2004, 58).
In addition to the shortcomings in implementation, the National Programme itself was
created in haste, and was therefore not evidence-based. Instead, the NP was founded on
conventional public health wisdom with regard to HIV/AIDS, and is coated in ambiguity. For
educational and prevention programs to yield expected results (i.e. condom use or identification
of HIV-related facts and myths), they should be tailored to target audiences (i.e. risk groups such
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as MSM, CSWs or IDUs) and based on data stemming from individuals within targeted groups.
Moreover, the NP though extensive, does not address all possible high-impact prevention
strategies. Circumcision, known to decrease the transmission of HIV, is not listed as a strategy
within the NPs framework; such exclusion may be problematic as heterosexual transmission
grows in prevalence. Needle exchange programs exist in Armenia as a result of the Open Society
Institute networkneither through the Ministry of Health nor the NP. It is unknown whether
these approaches were excluded due to a lack of funding, or a politically conservative
government unwilling to adapt to controversial HIV control methods such as the implementation
of NEPs. Ultimately, the success of prevention under the NP is dependent on an entirely holistic
approach, and NCAP should consider the inclusion of both circumcision as well as NEPs in the
NP to streamline prevention activities and reduce the incidence of new infections in addition to
continue to improve the implementation of current educational and behavioral change measures
if resources permit.
Gaps in Political Climate and Commitments for Funding:
Although international funding is the lifeblood for HIV treatment, prevention, and control
activities in Armenia, future funding schemes remain undisclosed. The National Programme was
projected to need USD 22.5 million in funding from international sources to be implemented
fully from 2007-2011 (NCAP, Financial Resources, 38). The state provided more than its goal of
35% financial resources to implement the NP in 2010 and 2011 (UNGASS, 2012, 12).
Nevertheless, the majority of funding was derived from international sources and private donors.
From the Global Fund alone, Armenia received USD 21.6 million in grants for HIV programs
(Global Fund, 2012). However, the total amount spent on HIV activities within the country was
reported to have totaled only USD 17.1 million from 2007-2011 (UNGASS, 2012, 10). Thus, the
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reporting of funds for specific HIV activities is either incomplete, funds were not disbursed in
full, or actual costs were lower than predicted costs; the reason behind this discrepancy is
unknown. Regardless, Armenia needs a continuous supply of funding to continue the NP, but
momentarily, there is no concrete evidence indicating the continuation of such generous grant-
driven funding. Nevertheless, given Armenias unique relationship with the Global Fund, one
can assume that funding will continue throughout the next stage of the NP (Khachatryan, 2012,
2).
Under the assumption that international funding for HIV/AIDS will in fact continue, one
can conclude that the largest obstacle to HIV control within Armenia is not the lack of outside
funding, but instead, internal economic development. Tension among Armenia, Turkey, and
Azerbaijan is immense: formal diplomatic relations between Armenia, Turkey and Azerbaijan
are virtually non-existent, and as a result, trade is stifled between the countries. The very forces
that drive the spread of HIV within Armeniainjection drug use, rampant migration, and sex
workare created by broad diplomatic foibles that trickle down to the citizenry and cause
widespread poverty to persist.
Conclusion and Recommendations:
Although the proliferation of the National Programme into Armenias health care system
brought HIV into the political arena, Armenia is far from zero infections by 2015 due to the
incomplete nature of the NP, broad socioeconomic constraints caused by developmental delays,
and pervasive cultural stigmas. However, Armenia is not a hopeless state. Although it is unlikely
that no new infections will occur within Armenia by 2015, Armenia is in a position now to
ensure that it does not fall victim to a second-wave epidemic; HIV rates can be controlled, and
the incidence of new infections can be reversed.
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Effective HIV prevention programs have borne fruit in resource-poor settings, but
Armenias unique location, political quarrels with surrounding states, and socioeconomic
conditions require an entirely holistic approach to controlling the epidemic. Armenias weak
economic system not only inhibits investment in public health, but indirectly perpetuates HIV-
related risk activities. The unavailability of economic prospects within Armenia sets the stage for
social phenomena that make Armenias HIV/AIDS epidemic unique: migration, injection drug
use, and commercial sex work all arise as a result of grim financial prospects. Remittances from
migratory workers amount to an estimated 0.5% 0.7% of Armenias GDP (Chami et al, 2005,
68). Young, urban men, those most vulnerable to HIV, leave spouses and families behind to find
seasonal work in Russia or Ukraineboth areas with much higher HIV prevalence ratesand
risk behaviors such as engaging in commercial sex or injection drug use are correlated with such
migration (Buckley, 2005, 31). These migration patterns directly impact the HIV/AIDS epidemic
in Armenia: in the past three years, 60% of newly confirmed HIV infections in Armenia were
acquired outside of the country (Kvtisinadze et al, 2010, 32). Migrants, therefore, act as bridges
to HIV upon returning to Armenia, and the growing prevalence of heterosexual transmission
within Armenia cannot be understated as the risk of infecting non-migrant partners increases.
Young women or spouses of migrants left behind, too, may turn to sex work to make a living
thereby increasing their risk of acquiring HIV and further confounding the problem (Buckley,
2005, 30). Thus, migrants (usually males) who leave Armenia sans HIV are likely to return
positive and transmit the infection. Meanwhile, women left behind may spread the virus within
Armenias borders. The NP addresses the need to monitor and test migrant workers for HIV, but
this is not yet being done. Moreover, the Programme does not include the expansion of support
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to family networks of migrants to limit transmission, nor is cooperation with the neighboring
states that migrants move to and from addressed.
The recognition of migration and its correlation with risk behaviors as well as the
inclusion of monitoring, testing, and educating migrant populations in the NPs goals can indeed
slow the spread of HIV within Armenia, but HIV knows no borders. The eradication of HIV
within Armenia is intrinsically linked to its eradication in neighboring states so long as migratory
patterns remain embedded into the fabric of Armenias economic progression (Babayan, 1999,
10). Thus, there is need for Armenian health officials to coordinate HIV prevention strategies
targeted at migrants with neighboring states because transmission networks do not end at
borders. Current political tensions are cumbersome to necessary collaboration and impede on
Armenias ability to thrive economically. Therefore, concessions must be made to control the
spread of HIV not only within Armenia, but across the Southern Caucasus. This sort of
cooperation may open the pathway to the lessoning of political tension to thereby increase the
rate of economic development in Armenia, as well, thus further aiding the fight against
HIV/AIDS.
While significant national and international resources have been devoted to the fight
against HIV, the eradication of HIV in Armenia will not occur by 2015 because current
HIV/AIDS treatment, prevention, and control efforts are not grounded in human rights.
Ultimately, HIV/AIDS cannot be eradicated until a human rights-based approach to controlling
the epidemic is adopted. A travel ban on HIV positive individuals was lifted in 2011, and the NP
cites the reduction of stigmatization of risk populations as a necessary component and expected
outcome in the fight against HIV, yet national legal conventions and prevailing sociocultural
paradigms perpetuate such stigmas and inhibit real changes in public perceptions (UNAIDS,
Babayan 19

2012). Armenias heavy criminalization of drug use in a zero tolerance approach is inherently
stigmatizing because such a policy reinforces the general distaste and demonization of injection
drugs and their users. Moreover, drugs such as methadone and buprenorphine that are needed for
substitution therapies endorsed by the NP are illegal under the Armenian Law on Narcotic Drugs
(Markosyan et al, 2006, 139). Therefore, Armenian law overtly undermines the progression of
the NP meanwhile pushing IDUs further away from mainstream society and complicating
surveillance and treatment efforts. Self-identification as a homosexual, injection drug user or sex
worker, as discussed earlier, is discouraged because of prevailing conservative values that are the
root of Armenian society. Such groups must be treated with dignity in order to first properly
obtain epidemiological indicators of the HIV epidemic in Armenia as well as implement
preventative and behavioral change educational programs to their fullest extent. Moreover, as the
HIV epidemic shifts from one of injection drug use to one of heterosexual contact, womens
rights will grow in importance to combating HIV/AIDS (Patterson and London, 2002, 967). The
prevailing social norm of violence against women and the absence of legal ramifications for
harming women in Armenia may accentuate the spread of the epidemic in the future, and
womens rights should also be addressed by future prevention programs to quell the persistence
of HIV in Armenia. The Open Society Institute in Armenia has introduced the framework for
rights-based approaches to HIV prevention into the NP, but the rights-based paradigm has not
yet permeated the minds of all citizens, health officials, and government administrators;
therefore, social barriers to HIV prevention, and treatment will inhibit Armenias ability to reach
zero infections as soon as 2015, but the prospect is not unheard of later on in the future.
However, perceptions change only when there is will to change them. Ultimately, Armenian
Babayan 20

health officials and politicians should make the advancement of human rights a priority to both
directly and indirectly subdue the spread of HIV.
Although zero new HIV infections by 2015 is not a goal that is attainable in Armenia,
shifting attention and resources to HIV treatment, prevention, and control may reduce Armenias
vulnerability in becoming part of the second wave reemergence of HIV. Poverty, persistent
migration, and drug use as well as discriminatory paradigms require long term commitments to
solve, but Armenia is presently equipped with the potential to immediately implement programs
and policies to reduce transmission of HIV within its borders. Armenias commitment to scaling
up biomedical prevention programs by utilizing blood screening centers and integrating HIV
treatment facilities and resources into existing systems remains crucial. However, the creation of
such resources is virtually fruitless unless they are accessed by those most in need and general
knowledge of sexual health is increased. Quelling stigmatization and discrimination to further
encourage the use of HIV services can only be done if Armenian officials eliminate
discriminatory laws because HIV/AIDS is ultimately an issue of human rights and dignity. IDUs,
CSWs, and MSM can be better reached if human rights act as the foundation to all HIV
campaigns and related activities. The allocation of resources to expand surveillance beyond the
national registry would further aid the distribution of resources to populations at highest risk and
most in need. Evidence-based educational and behavioral change prevention programs should be
developed and put into use, but surveys among and analysis of target populations must first take
place for these programs be efficacious. As the HIV/AIDS within Armenia moves to become one
of heterosexual transmission, the importance of increasing knowledge of sexual health among all
individuals is paramount, and the Ministry of Health must continue educational efforts. Special
attention should be given to migrant populations with regard to HIV, but diverting resources to
Babayan 21

migrant populations alone will not guarantee the halt of HIV transmissions. Instead, cooperation
with neighboring states Ministries of Health is necessary to ensure migrating individuals avoid
infection and transmission. The NP at its present state will not slow the dissemination of HIV
across Armenia alone, but it can act as the platform upon to implement programs that will aid in
the reduction of HIV transmissions.
Armenia is by no means a perfect state, but hope for the eradication of HIV/AIDS within
the country exists. The Armenian HIV/AIDS epidemic can be extinguished, though not by 2015.
Instead, the progression of the HIV epidemic can be slowed through the continuation and
improvement of the National Programme, the integration of basic human rights into health
systems and society, and the movement toward economic development through reconciliation
with those who manage borders as well attention toward the people who cross them.
Babayan 22

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