shortcomings also exist in the management of opportunistic infections, most significantly in the quality of diagnosis and treatment of tuberculosis (TB), which is the leading cause of death among AIDS patients. The design and implementation of programmes for medical care and treatment partially meet current needs. In order to meet future needs, extensive revisions and improvements are needed in the strategy for the provision of treatment services and for the availability of adequate infrastructure and other resources. The most urgent issues that require attention are the decentralization of the provision of ART, the rapid scale-up of methadone-based OST, and the effective prevention, diagnosis and treatment of TB among people living with HIV. The large projected increase in the number of people living with HIV in need of treatment and support represents a serious challenge for the Ukrainian medical system, which remains ill-equipped to manage a task of such scope and complexity. Urgent measures need to be taken to plan and implement the decentralized and integrated provision of medical care and treatment for people living with HIV, based on the successful experience in Donetsk oblast. Systemic shortcomings also need to be addressed in this area, requiring extensive time and effort. These include the excessively high prices for some ART medications procured through the Ministry of Health, widespread illegal out of pocket payments by patients for diagnostic and some medical services, widespread stigma and discrimination faced by people living with HIV and members of vulnerable groups, and the lack of integrated, patientoriented services. Effective treatment is hampered by the highly vertical nature of the medical system in Ukraine which is not focused on the needs of patients. Patients with multiple conditions (HIV, TB, opiate drug dependence) must visit different specialized health services almost daily, and often receive uncoordinated or inappropriate treatment and care. Approaches to provide integrated treatment and care services have been successfully piloted in select clinics, such as the Kyiv City AIDS Centre, and should be rapidly scaled up to other cities and regions. The overall number of personnel working in the treatment and care of HIV is inadequate to meet future needs, underscored by the absence of a national plan for human resource development for AIDS. 1.4.7
Non-Medical Care and Support Importance: Medium Progress: Inadequate
A range of important non-medical care and support services now exists for people living with HIV in Ukraine. The majority of these services are being implemented by over 50 NGOs, mainly in large Ukrainian cities, and supported primarily by the Global Fund grants. Some of these services have produced notable outcomes in improving the quality of life for clients, particularly in the areas of adherence counselling, care for orphans and vulnerable children affected by HIV, and peer support for people living with HIV. However, the coverage of care and support services remains extremely low and inadequate to meet the scope and complexity of existing and future needs. As of the end of 2007, care and support services provided through the All-Ukrainian Network of People Living with HIV (Network) reached a cumulative number of 27,500 adults and children. This represents only 33% of all persons reported with HIV-infection, and only 6% of all persons estimated to be living with HIV in Ukraine. The integrated care and support services that are currently available are provided at high cost for a small number of clients, without adequate focus on providing essential services for the most vulnerable clients. A large and growing number of people living with HIV do not have access to these services. This makes it increasingly difficult for organizations providing these services to focus on reaching persons living with HIV who need essential care and support services, instead of sustaining support for clients that access other, non-essential services that may be less viable to sustain. Care and support services should be replanned to ensure equitable coverage and sustainability for the most essential services. Variations in 19