In the lead-up to AIDS 2026 and as part of the Rethink. Rebuild. Rise. campaign, VirusOFF continues its series on what HIV prevention looks like today in Central and Eastern Europe and Central Asia — not in abstract strategies, but in the real lives of people facing stigma, unstable funding, migration, criminalization, unequal access to health care and a lack of trust in systems.

One of the main principles of modern HIV prevention is choice. There is no single tool that works equally well for everyone. For one person, the key may be testing and access to treatment. For another, it may be pre-exposure prophylaxis. For someone else, it may be condoms, harm reduction services, opioid agonist therapy, support from a peer counsellor, a safe conversation with a doctor, psychological support or the possibility of receiving information without fear of judgement.

That is why the concept of prevention choice is increasingly present in the global agenda. It is not about expecting a person to choose the “right” single path. It is about ensuring that people have real access to different evidence-based options for HIV prevention — without stigma, pressure, discrimination or bureaucratic barriers.

For our region, this is not a theoretical discussion. According to UNAIDS, the annual number of new HIV infections in Eastern Europe and Central Asia continues to rise: in 2024, it reached approximately 130,000, a 7% increase compared with 2010. Around 2.1 million people are living with HIV in the region, but only 51% are receiving the treatment they need, while data on viral suppression remain insufficient or incomplete. This means that prevention cannot be treated as a secondary issue — it must become part of a wider system of access, trust and support.

Combination prevention: what it means in simple terms

Modern HIV prevention is not one method. It is a combination of tools that should be available to people depending on their lives, needs, relationships, health, migration experience, legal status, financial situation and level of safety.

This kind of prevention includes:

• HIV testing — regular, accessible, confidential, free from stigma and fear of consequences.
• Condoms and lubricants — a basic but still critically important tool for preventing HIV and other sexually transmitted infections.
• Pre-exposure prophylaxis (PrEP) — the use of antiretroviral medicines before a possible exposure to HIV to prevent transmission.
• Post-exposure prophylaxis (PEP) — a short course of medicines after a potential exposure to HIV, which should be started as soon as possible, usually within 72 hours.
• Undetectable = Untransmittable (U=U) — the principle that a person living with HIV who is on treatment and has an undetectable viral load does not transmit HIV sexually. UNAIDS also emphasizes that viral suppression through antiretroviral therapy is an important part of combination HIV prevention.
• Harm reduction — including access to sterile injecting equipment, opioid agonist therapy, naloxone, and testing and treatment for HIV, viral hepatitis and tuberculosis for people who use drugs.
• Access to HIV treatment — not only as a human right, but also as part of prevention.
• Psychological, social and peer support — because people cannot always use a medical tool if they are afraid of the system, do not trust doctors, do not have documents, are in crisis or do not know where to turn.

WHO also emphasizes that HIV prevention should be integrated with prevention, testing and treatment for viral hepatitis and sexually transmitted infections, as well as with sexual and reproductive health services and mental health support. In other words, effective HIV prevention is not only about pills or a test; it is a system that sees the person as a whole.

Why a “one-size-fits-all” approach does not work

In Central and Eastern Europe and Central Asia, barriers to HIV prevention are very different — and often overlap.

For people who use drugs, the key issues may be access to harm reduction, sterile injecting equipment, opioid agonist therapy, HIV and hepatitis testing, and treatment without fear of criminalization. In its 2024 global review, Harm Reduction International notes that although the number of countries where sterile injecting equipment programmes and opioid agonist therapy are available has increased slightly worldwide, coverage remains uneven and limited, while stigmatization and criminalization of people who use drugs continue to undermine access to services.

For people in migration, the problem may not only be the absence of a service, but also documents, insurance, language, lack of knowledge of the system or fear of losing work or legal status. In its 2024 report on HIV and migrants in the EU/EEA, ECDC found that only seven countries reported medium or high coverage of condom and lubricant programmes for migrants; data on migrants’ access to PrEP remained limited, and 13 countries reported difficulties reaching both documented and undocumented migrants.

For people without documents or with unstable legal status, prevention often becomes almost unreachable. According to ECDC data on PrEP in Europe and Central Asia, based on data collected in 2024, 14 countries reported that PrEP was available to undocumented migrants through the health-care system if they met the eligibility criteria, while 16 countries reported that PrEP was not available to them. In some countries, PrEP may be formally available but remain difficult to access in practice because of complex procedures, out-of-pocket payment or other barriers.

For women in migration, HIV prevention also cannot be reduced to the phrase “see a doctor”. Safe sexual and reproductive health services, non-judgemental testing, access to information, psychological support and attention to the experience of war, violence, childcare, financial instability and lack of time are all needed.

For people living with HIV, prevention means continuous access to treatment, laboratory monitoring, support for adherence and information about U=U — without shame, blame or fear-based language.

PrEP exists, but is there access?

PrEP is often presented as a symbol of a new era in HIV prevention. And it is indeed one of the most important tools. But the inclusion of PrEP in national guidelines does not yet mean real access.

ECDC’s report on PrEP in Europe and Central Asia, based on 2024 monitoring data, notes that PrEP provision has expanded significantly since 2016, but access and use remain unequal. In many countries, PrEP is mainly provided in highly specialized health-care settings, including infectious disease, HIV or sexual health clinics. At the same time, only a small number of countries reported providing PrEP through community organisations, pharmacies or other less medicalized access points.

This matters for our region. If PrEP is available only in a large city, only through a specialized clinic, only through a complex procedure or only for some communities, it does not become a real choice. For a person who fears stigma, lacks documents, lives far from the capital, does not speak the local language or does not trust the health system, this “access” may exist only on paper.

It is equally important not to set PrEP against other tools. PrEP does not replace condoms for preventing other sexually transmitted infections. It does not replace harm reduction for people who use drugs. It does not replace U=U, testing, treatment, mental health support or peer support.

PrEP is part of choice. But choice begins only where a person can genuinely use different options.

U=U: prevention without stigma

For a region where stigma remains one of the main barriers, the principle of U=U has not only medical but also social significance.

U=U says it simply: if a person living with HIV is receiving effective treatment and has an undetectable viral load, they do not transmit HIV sexually. This changes not only how prevention is understood, but also the language we use to talk about HIV.

It means that a person living with HIV is not a “threat”. They have the right to relationships, sexuality, family, planning for the future, work, migration, safety and dignity.

But U=U works only when there is access to testing, treatment, laboratory monitoring, counselling and support. If a person does not know their status because they fear testing; if they cannot start treatment because of documents; if they lose access to therapy after moving; if they cannot check their viral load — then a scientific principle does not become reality.

That is why U=U is not just a message for a poster. It is a demand on the health-care system.

Harm reduction is not a separate track, but a foundation of prevention

In Central and Eastern Europe and Central Asia, harm reduction remains one of the key conditions for effective HIV prevention. This is especially true for people who use drugs, people in places of detention, people without stable housing, people without documents and those who avoid state institutions because of previous experiences of stigma or persecution.

Harm reduction is not an “encouragement” to use drugs. It is an evidence-based approach that reduces health risks, keeps people connected to systems of support and opens the way to testing, treatment, social support and the rebuilding of trust.

That is why sterile injecting equipment programmes, opioid agonist therapy, naloxone, testing for HIV, viral hepatitis and tuberculosis, and peer counselling services should be part of a single HIV prevention package.

If harm reduction is cut, criminalized or pushed to the margins, HIV prevention loses one of its foundations.

Community-led work: where trust begins

In many countries of the region, community organisations remain the place where people can turn without fear.

Peer counsellors, outreach workers, navigators, civil society and migrant organisations often explain what the system has not explained: where to go, what documents are needed, where to get tested, how to access treatment, how to talk to a doctor, what to do after moving, how not to lose therapy and how to overcome fear.

For a person, this can be the difference between “I will not go anywhere” and “I will try to seek help”.

That is why funding community work cannot be considered an “additional component”. It is prevention infrastructure. Without it, medical tools often do not reach the people who need them most.

In the new Global AIDS Strategy 2026–2031, UNAIDS sets a 2030 target for 90% of people who need prevention to be using appropriate options, including PrEP, PEP, condoms, sterile injecting equipment programmes and opioid agonist therapy. This cannot be achieved without services that work where people live and speak a language they trust.

What “choice” means for our region

In Central and Eastern Europe and Central Asia, “choice in prevention” must mean concrete changes, not just a beautiful phrase.

It means that a person can get an HIV test without fear of judgement.

It means that PrEP is available not only in the capital and not only to those who have money, documents, knowledge of the system and the courage to go through a complicated pathway.

It means that PEP can be obtained in time, not after the critical 72 hours have passed.

It means that condoms and lubricants are available where they are needed.

It means that people who use drugs have access to harm reduction, not criminalization.

It means that people living with HIV have continuous treatment and can talk about U=U without shame.

It means that refugees, migrants, people without documents and internally displaced people do not fall out of the system because of their legal status.

It means that prevention includes mental health, sexual and reproductive health, social support and protection from discrimination.

And it means that a person should not have to prove that they “deserve” prevention.

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