Ahead of AIDS 2026 and as part of the Rethink. Rebuild. Rise. campaign, VirusOFF is preparing a series of materials on what HIV prevention looks like today in Eastern Europe and Central Asia — in the context of migration, war, unstable funding, stigma and unequal access to services.
For the region, this is a period of renewed uncertainty: international support is shrinking, civic space is narrowing and criminalization and attacks on human rights are increasing pressure on organizations that for years have served as a bridge between people and the health system. In such conditions, HIV prevention cannot be reduced to medical tools alone — it directly depends on trust, rights, harm reduction, community work and access to services without fear or judgement.
Two years ago, ahead of AIDS 2024 in Munich, VirusOFF spoke with Ganna Dovbakh, Executive Director of the Eurasian Harm Reduction Association and Chair of the EU Civil Society Forum on Drugs, about decriminalization, the power of communities and why an effective HIV response is impossible without human rights and the meaningful participation of communities themselves.
Today, this conversation feels even more urgent. We continue it in the context of AIDS 2026 in Rio — about what happens to HIV prevention when resources disappear; why harm reduction is not an “additional component” but a central part of the response to the epidemic; and what questions Eastern Europe and Central Asia should bring to AIDS 2026.
— Ganna, we spoke before AIDS 2024 in Munich about decriminalization and the power of communities. Looking back at these two years, what has changed the most for HIV prevention in Eastern Europe and Central Asia?
Ganna: The biggest change has been the rapid restructuring and, in practice, the disappearance of a significant share of financial resources for civil society organizations.
The work that civil society organizations had been doing for years with the support of international donors is now under the very real threat of disappearing. For our region, this is especially critical because Eastern Europe and Central Asia have been highly dependent on international funding — particularly for programmes for key populations, prevention, testing, support for access to treatment and services related to HIV, tuberculosis, hepatitis and harm reduction.
In many countries, it was civil society organizations that provided focused prevention for people who often do not reach state services. These were the programmes hit first: some have closed, some have been reduced to a minimum and some have effectively lost the ability to work systematically.
This is not only a regional story — it is a global process. But for our region, it is especially dangerous because there was already strong dependence on external resources, while state funding for services for key communities remains very limited or unstable.
Another problem is that, in the context of funding cuts, states often choose a more “medicalized” response: treatment, procurement and sometimes even renovations or infrastructure needs. Community interventions, outreach, peer counselling, community-led monitoring, advocacy, legal aid and support for people in accessing services start to be seen as secondary. Yet these are often the very conditions that enable a person to enter the health system at all.
— How would you describe the current state of HIV prevention for key communities in our region: are we moving towards greater choice and access, or are we seeing opportunities narrow?
Ganna: Formally, there are more tools: PrEP, PEP, testing, treatment, modern approaches and new medicines. But real access is not only about having a medicine in stock or in a doctor’s office.
A person has to reach that office. They have to trust the doctor, not be afraid of the reception desk, not be afraid that their data will be shared somewhere or that their behaviour or status will become grounds for persecution or stigma. If this is missing, prevention exists only on paper.
So I would put it this way: at the level of technologies and medical tools, there seem to be more opportunities. But at the level of real access for key communities, we are seeing a serious narrowing. And it is linked not only to funding, but also to the political context, stigma, criminalization, distrust of institutions and pressure on civil society.
— Harm reduction is still sometimes seen as a separate area. How would you explain why it is not an “add-on” but a central part of HIV prevention?
Ganna: Harm reduction is not a set of syringes or wipes. It is an approach that makes it possible to work with people’s real behaviour, rather than with the system’s ideas of how people should be.
The drug market is changing. Substances are changing, the ways they are bought and used are changing and the groups of people facing risks are changing. Accordingly, harm reduction must also change. In some places syringes are needed; in others, drug checking; elsewhere, peer counsellors among young people at festivals; elsewhere, information on overdose, safer practices, access to opioid agonist therapy, HIV and hepatitis testing, and psychosocial support.
But the essence is the same: it is a way to reduce the risks of death, acquiring or transmitting HIV and hepatitis, mental health crises, violence and isolation. It is also a way to connect a person with the health system.
That is why harm reduction is not an “add-on” to HIV prevention. It is one of its central parts. Without it, we lose people who need support the most and who are the hardest to reach through ordinary medical channels.
— What blocks access the most today for people who use psychoactive substances to prevention, testing, PrEP/PEP, HIV treatment, hepatitis C treatment, opioid agonist therapy and other services?
Ganna: First and foremost — criminalization and fear.
When a person’s behaviour itself is criminalized or can be used against them, they will not trust the system. If a person is afraid of the police, afraid of the doctor, afraid that seeking help may expose them to the risk of persecution, they will not go for testing, will not seek PrEP, will not speak honestly about risks and will not come for treatment.
This does not concern only people who use drugs. It is relevant for sex workers, people living with HIV, LGBTIQ+ people and other marginalized groups. In some countries of the region, consensual same-sex relations between adults are still criminalized. In others, HIV transmission, or even perceived exposure to HIV transmission, is criminalized. In some places, because of extremely small quantities of substances, a person can face criminal prosecution even because of residue in a syringe.
All of this pushes people beyond the reach of medical care. And then it does not matter that somewhere in the system there is PrEP, testing equipment or medicines. If a person does not trust the system and is afraid to approach it, prevention does not work.
— In 2024, you actively promoted the Rise & Decriminalize campaign. What is happening with this movement now: what has been achieved and what has proved most difficult?
Ganna: We launched Rise & Decriminalize as a regional initiative and a movement of different networks and communities. Today, this work continues, including thanks to the support of the Elton John AIDS Foundation.
One of the main tasks now is to document negative trends in legislation affecting the work of civil society organizations in real time. Together with partner networks, we are monitoring the shrinking of civic space for marginalized groups in the countries of the region: “foreign agent” laws, attacks on international funding, rhetoric about “drug propaganda” or “LGBT propaganda” and attempts to restrict the work of organizations providing services to key populations.
The most important thing we have managed to do is to show the world the technologies of autocratic states: criminalization is not only about people’s behaviour. In many countries, the very possibility of providing services to these people, speaking about their rights, receiving international funding and collecting data on human rights violations is gradually being criminalized or placed under threat.
The most difficult thing is that these trends are intensifying quickly. They do not always look like a direct ban. Sometimes it begins with political rhetoric, with talk about “foreign influence”, “propaganda” and “protecting traditional values”. But then it turns into laws, restrictions and criminal risks for organizations and people.
— How can decriminalization be explained today to people outside the field — not as a political slogan, but as a practical condition for effective HIV prevention?
Ganna: I would explain it very simply: a person’s life and everyday behaviour should not be criminalized if they are not causing harm to others.
If a person uses drugs, provides sexual services, lives with HIV or has consensual sexual relations with another adult, this should not automatically make them a criminal. Criminalization cannot stop this behaviour; it does not work that way. Criminal punishment only makes people invisible to health care, social services and prevention programmes.
When people are afraid that seeking help may be used against them, they do not seek help. They do not get tested, they do not report overdoses, they do not come for PrEP, they do not speak honestly with doctors and they do not receive HIV or hepatitis C treatment.
That is why decriminalization is not an abstract political demand. It is a practical condition for HIV prevention to have a chance to work.
— What happens to prevention when people do not trust doctors, social services, the police or state institutions?
Ganna: Prevention becomes a formality.
You can procure medicines, open an office, write a good protocol and call a service “friendly” or “low-threshold”. But if a person is afraid to pass through the reception desk, if they expect judgement, disclosure of their status, police interest or a bureaucratic trap, they will not come.
Trust is not a soft component. It is the infrastructure of prevention. Without trust, people remain outside the system. And if they are outside the system and there is no support from peer counsellors, then prevention, testing, treatment and support do not reach them.
— Why do peer counsellors, outreach workers and community organizations often remain the last bridge between people and the health system? And what does a person lose when this bridge collapses?
Ganna: Because they are the ones trusted by highly stigmatized people. They know people’s real lives, understand the risks, the language, the fears and the context. They can explain, accompany, support, find a pathway and help a person avoid disappearing between offices, laws and institutions.
This is competence built over years. It cannot be quickly restored after organizations disappear.
There are painful examples from other countries. When, after the end of Global Fund support, the state did not take over funding for harm reduction, organizations held on for some time, but it is impossible to provide services for long without salaries and resources. People moved into other fields, left the country, burned out or lost faith. And when, a few years later, the state realized that the services had disappeared, it turned out that they had to be rebuilt almost from scratch.
Recommendations, protocols and guaranteed service packages are important. But if there are no people who know how to work with communities and have their trust, these documents do not work.
— Prevention in the context of shrinking or unstable funding. What is the first to “fall” when resources are cut?
Ganna: The first to fall are usually the components that the system mistakenly considers “additional”: advocacy, training, meetings, monitoring, community support, legal and paralegal aid, peer counselling, outreach and the participation of communities in decision-making.
But these components are often the foundation of access. They explain to people where to go; accompany them; document violations; help the system see what is really happening; and protect the space for services.
When these are cut, we do not simply lose “activities”. We lose people who have spent years building trust, expertise and connections with communities. And this can no longer be quickly restored through one new call for proposals or one new procurement process.
— How would you explain to a donor or a decision-maker that funding harm reduction and community work is not an “additional component”, but a condition for the effectiveness of HIV prevention as a whole?
Ganna: I would say: if you believe it is enough to bring medicines to a hospital or place PrEP in an office, show how people will get there.
Who will explain to a person that this is for them? Who will help them overcome fear? Who will be there if they have experienced violence, stigma, criminalization, risks of deportation, loss of documents or distrust of the state? Who will be able to speak with them in a language of trust?
Without communities, peer counsellors and harm reduction, the HIV response is narrowed down to a medical warehouse and an office. But prevention is not only syringes or a medicine. It is a conversation between one person and another, and a person’s pathway to that medicine. And this pathway is often created by civil society organizations.
— Can we say that protecting civil society, especially in the context of war, political pressure and shrinking space for civil society organizations, is also part of HIV prevention?
Ganna: Yes, absolutely. Protecting civil society is part of HIV prevention, because it is often civil society that provides services the state does not reach or is not trusted to provide.
When organizations are shut down, when international funding is restricted, when people are frightened with the label of “foreign agent”, when information or services for key populations are criminalized — this is not an abstract attack on NGOs. It is a direct strike against a person’s pathway to support.
Civil society organizations do not only provide services. They document violations, speak about rights, support the participation of communities in decision-making and maintain contact with people whom the system does not see. If this space disappears, HIV prevention becomes weaker, less precise and less accessible.
— The AIDS 2026 slogan is Rethink. Rebuild. Rise. If applied to HIV prevention in Eastern Europe and Central Asia, what exactly do we need to rethink, what do we need to rebuild and what should communities rise around together?
Ganna: We need to rethink the role of communities. Not as an “add-on” to the system, not as a convenient partner for projects, but as a central part of the response to the epidemic.
We need to rebuild the funding system. If everyone talks about institutionalization, it must not mean that communities disappear and the state keeps only the medical part. Institutionalization must include sustainable funding mechanisms for civil society and community-led services, outreach, peer counselling, advocacy, monitoring and legal support.
And communities need to rise around solidarity and the protection of themselves. The pressure is very strong. And if we do not hold together — regionally, globally, across different communities, and between human rights, medical and research environments — we will lose not only individual programmes. We will lose the infrastructure of trust without which HIV prevention does not work.
— If you had to formulate three main questions from the EECA region to AIDS 2026 in Rio on HIV prevention, what would they be?
Ganna: The first question: does the global HIV response have a real plan for preserving focused prevention for key communities in the context of shrinking international funding?
The second: are pharmaceutical companies, private donors, the academic community, international organizations and states ready to systematically and in a coordinated way support not only medicines and technologies, but also civil society organizations, harm reduction, peer counselling, advocacy, community research and the protection of civic space?
The third: if the HIV response is being narrowed down to treatment in hospitals, who exactly will bring there the people who, because of criminalization, stigma and fear, do not trust the system?
Because I do not believe that without focused prevention, without networks of trusted peer counsellors and without community organizations, treatment on its own will reach those who need it most.
— And to conclude: finish the sentence. HIV prevention in our region will not work if…
Ganna: …if civil society organizations are banned.
Because it is often they who remain the bridge connecting a person with information, prevention, treatment, rights and support. If this bridge is destroyed, the system may still have medicines, protocols and offices — but not the people all of this was supposed to reach.
