Ազգային զեկույց 2023թ.

Overview 

By 2023, the estimated number of adults and children living with HIV (PLHIV) in Armenia reached 6,300. The HIV prevalence rate among adults aged 15-49 years was 0.4%, with rates of 0.2% in women and 0.5% in men. The prevalence among young women and men (aged 15–24 years) was less than 0.1%. Approximately 540 new infections occurred annually, primarily among adults, with an estimated incidence rate of 0.19 per 1,000 in the 15-49 age group. Deaths due to AIDS were estimated to be fewer than 100. Between 2010 and 2023, new HIV infections increased by 49.7%, and AIDS-related deaths rose by 143%. From 1988 to the end of 2023, Armenia recorded a cumulative total of 5,614 HIV cases, 2,269 AIDS cases, and 1,186 deaths among its citizens. In 2023, 500 new HIV diagnoses were reported, with a rate of 16.7 new infections per 100,000 population.

The increased number of new diagnoses in recent years is likely due to higher testing rates.  According to the surveillance data, the number of diagnostic tests for HIV has risen by 28% when comparing data from 2019. Concurrently, we record 12% increase in new diagnoses of HIV cases during the same period. Surveillance data also reveals that many people living with HIV are diagnosed late, with 59.6% diagnosed when their CD4 count was below 350 cells/mm3 in 2022. Advanced HIV infection with CD4 counts below 200 cells/mm3 was seen in 42.2% of new diagnoses. A recency survey conducted in 2022 showed an increase compared to 2018 and 2021, with only 17.2% of new diagnoses being recent infections.

In 2023, the predominant mode of HIV transmission in Armenia was heterosexual, accounting for 82% of new diagnoses. This was followed by transmission through sex between men (11%), injecting drug use (3%), and mother-to-child transmission or blood/blood products (1%). The mode of transmission was unknown or missing for 2% of cases. Between 2017 and 2023, 69% of newly diagnosed HIV infections occurred among individuals with a history of travel abroad, labor migration, or their partners. Of those with a labor migrant history, 91% had connections to Russia. HIV transmission remains concentrated among key populations and people with history of economic migration, with a prevalence of 5% among men who have sex with men (MSM) and less than 3% among other key populations and people with history of economic migration.

Regarding gender and age distribution in 2023, 69.2% of HIV diagnoses were in men, 30.8% in women, and 4.2% in young people aged 15-24 years. The proportion of HIV diagnoses among persons aged 15-24 years has declined from 7.6% in 2019 to 4.2% in 2023. HIV is more frequently reported in males, who comprise over two-thirds of registered diagnoses. Among adults, those aged 25-39 years are the most affected group, accounting for 49% of diagnoses in both women and men. The highest number of new diagnoses was among men aged 25-29 years, while women aged 35-39 years were most affected. Nearly 20% of reported HIV infections in Armenia are among individuals older than reproductive age , with 24% of HIV diagnoses in 2023 occurring in this age group, predominantly affecting women. In 2023, 24% of the newly detected HIV cases were among individuals aged 50 and older. Geographically, more than a quarter (26.4%) of newly diagnosed HIV infections in 2023 were reported in Yerevan, the capital. Shirak, Lori, and Gegharkunik provinces followed with 11.6%, 10.6%, and 10.2%, respectively. These provinces also reported the highest HIV prevalence rates, with 275 cases per 100,000 population in Shirak, 248 in Lori, and 235 in Gegharkunik.

Armenia has faced significant socio-political and economic challenges in recent years, including the 2020 impacts of the COVID-19 pandemic and the conflict with Azerbaijan, as well as the displacement of ethnic Armenians from Nagorno-Karabakh in 2023. Despite these difficulties, the economy has shown resilience, thanks to careful macroeconomic policies such as active inflation control, fiscal responsibility, and effective oversight of the financial sector. In 2022, Armenia achieved impressive economic growth of 12.6%, driven by increased migration, business activity, and capital influx. This positive trend continued into the first half of 2023, with notable contributions from the IT, trade, and transportation sectors.

Since October 2023, the Armenian government has registered 115,183 refugees from the Karabakh region, including 30,000 children. The forced displacement has significantly disrupted the lives and livelihoods of these refugees, creating urgent humanitarian needs. Immediate challenges include providing shelter, food, healthcare, and psychological support. Additionally, there are substantial legal hurdles that require extensive efforts to address.

Political declaration and monitoring framework 1. Combination HIV prevention for all

Armenia's HIV epidemic remains concentrated among key populations, as indicated by multiple rounds of Bio-Behavioral Surveys (IBBS). The most recent surveys in 2021 revealed increased HIV prevalence among several key populations: gay men and other men who have sex with men

 registered an increase from 2.7% to 5.0%, people who inject drugs from 2.2% to 2.6%, and transgender people from 2.0% to 2.5% (IBBS 2021). Notably, the highest HIV prevalence was observed in Gyumri among people who inject drugs (6.0%), followed by Yerevan among gay men and other men who have sex with men  (5.2%). Among urban male labor migrants tested in 2018, HIV prevalence was 1.2% (IBBS in Migrants 2018).

Based on the 2021 data, size estimates for key populations have been significantly adjusted upwards: from 9,005 to 14,110 for people who inject drugs (a 56.7% increase), from 4,600 to 8,140 for sex workers (a 76.9% increase), from 16,100 to 22,716 for men who have sex with men (a 41.1% increase), and from 100 to 1,015 for transgender people (a 915% increase) (IBBS 2021). Armenia's HIV epidemic remains concentrated among key populations, as indicated by recent Bio-Behavioral Surveys (IBBS 2021). The latest surveys in 2021 revealed rising HIV prevalence across several key groups: men who have sex with men increased from 2.7% to 5.0%, people who inject drugs from 2.2% to 2.6%, and transgender people from 2.0% to 2.5%. Notably, Gyumri recorded the highest prevalence among people who inject drugs (6.0%), followed by Yerevan among men who have sex with men (5.2%).

Armenia has implemented comprehensive NGO-led HIV prevention programs for key populations since 2003. In 2023, 18,156 individuals at highest risk received preventive services through online, outreach, mobile, and stationary NGO sites, covering 39.5% based on the new size estimates. Despite annual increases in absolute numbers, the 2023 percentage coverage is over 30% lower compared to 2022 due to a 54% increase in size estimates. Community-based testing as part of preventive services saw increased coverage: 99% for men who have sex with men, 88% for transgender individuals, 94% for people who inject drugs, and 98% for sex workers in 2023.

Since 2019, the National Center for Infectious Diseases (NCID) has contracted NGOs to deliver specific service packages. These include HIV/AIDS and STI counseling, awareness, testing availability information, referral services, and provision of prevention supplies (condoms, lubricants, needles, syringes, alcohol swabs twice yearly). Pre- and post-test counseling and rapid HIV self-tests are provided annually or 1.5 times per year, with confirmed HIV-positive cases referred to NCID for further care.

Opioid Agonist Maintenance Treatment (OAMT) is available at the National Center of Addiction Management (NCAM), regional sites, and in prisons under the Ministry of Justice. By end-2023, 840 individuals were on OAMT, close to the 850-target. New OAMT recipients are linked to NCID for HIV and HCV testing and treatment every 6-12 months. Of those on OAMT, 9% are living with HIV (40 individuals), all on ART.

Introduced in 2017 at NCID, Pre-exposure Prophylaxis (PrEP) is accessible for those at HIV risk, with free access for key populations. The number of PrEP recipients rose from 43 in 2022 to 77 in 2023, mainly among men who have sex with men (95%), with 5% from HIV-discordant pairs. CSOs enhance awareness and demand for PrEP among key populations to expand access.

Political declaration and monitoring framework 2. 95–95–95 for HIV testing and treatment

Armenia has made significant strides towards achieving the 95-95-95 HIV targets, reflecting progress in its testing and treatment cascade. As of 2023, the country reported figures of 75-77-86, compared to 84-76-70 in 2019. Out of 5,900 people living with HIV, 4,428 (75%) were aware of their status, and among those aware, 3,398 (83%) were on antiretroviral therapy (ART). Notably, 86% of those on ART achieved viral suppression (<1000 copies/ml).

The first 95 target remains a challenge, with approximately 1,472 individuals yet to be reached for testing and enrollment into treatment. Despite challenges, Armenia conducted over 200,000 HIV screening tests in 2023, with 19.51% targeted at key and vulnerable populations, showing a higher positivity rate than general testing. Since decentralizing facility-based testing to primary care in 2019, Armenia has expanded HIV testing and counseling (HTC) using rapid diagnostic tests (RDTs), increasing from 17% in 2019 to 40% in 2023. This approach has been particularly effective among migrants and key populations, facilitating early detection and linkage to care. Community-based index testing has also been effective, detecting 14 HIV-positive cases among 49 individuals with high-risk heterosexual contacts in 2023, yielding a testing positivity rate of 29%.

Regarding ART coverage, Armenia has seen a steady increase in the number of people starting treatment, with 97% receiving regimens containing dolutegravir (DTG) and 95% on fixed-dose combinations. A partial decentralization pilot in Lori, Shirak, and Ararat regions has facilitated treatment access, with 137 individuals enrolled by the end of 2023.

While 86% of those on ART achieved viral suppression, challenges in testing all individuals on ART for viral load may affect accurate reporting of the third 95 target. Adherence to treatment remains crucial, with 59% maintaining treatment at 36 months post-initiation.

Armenia's commitment to optimizing HIV treatment and testing strategies underscores its efforts to achieve the 95-95-95 targets, despite ongoing challenges and the impact of COVID-19 restrictions on testing uptake.

Political declaration and monitoring framework 3. End paediatric AIDS and eliminate vertical transmission

Armenia has made substantial progress towards achieving the triple elimination of mother-to-child transmission (EMTCT) of HIV since 2016, earning validation from the WHO in 2018 and reaffirmation in 2021 as one of the first countries in the European region to reach this milestone. The cumulative total of HIV infections through vertical transmission stands at 54 cases reported in Armenia. In 2023, there were 5 newly diagnosed cases of HIV among infants and children, including two newborns.

Healthcare services for pregnant women, childbirth, and the postnatal period are provided free of charge through state programs in Armenia. The coverage of antiretroviral treatment (ART) for pregnant women living with HIV was 100%, ensuring effective prevention of vertical transmission. Similarly, ART coverage for newborns was also 100%. In 2023, 1 out of 2 infants born to HIV-positive women received early infant diagnosis (EID) for HIV within two months of birth. The triple elimination of mother-to-child transmission of HIV, syphilis, and hepatitis is a key priority in Armenia's long-term public health strategy. The Ministry of Health is actively working towards strengthening the healthcare system to achieve these goals. The upcoming EMTCT HIV report covering the 2021-2023 period, due in 2024, will highlight progress towards validating EMTCT of syphilis and efforts to enhance the syphilis elimination program.

As of December 2023, Armenia recorded a cumulative total of 84 HIV diagnoses among children, with 5 cases identified in 2023 (including two newborns). Unfortunately, four out of five HIV-exposed children did not receive antiretroviral prophylaxis and were breastfed for some duration, as their mothers were diagnosed with HIV post-partum. One case received PMTCT (prevention of mother-to-child transmission) but still acquired HIV. Nevertheless, all children born to HIV-positive women in 2023 received follow-up care.

Political declaration and monitoring framework 4. Gender equality and empowerment of women and girls

Armenia's HIV response is anchored in the National Program on HIV/AIDS Prevention for 2022-2026. This strategic framework outlines comprehensive actions aimed at enhancing the sustainability of the national HIV/AIDS response, reducing stigma and discrimination, and advancing human rights and gender equality. Key components of the program include:

1. Sustainability Strengthening: Measures are in place to ensure the long-term effectiveness and sustainability of HIV/AIDS prevention and treatment efforts in Armenia.
2. Stigma and Discrimination Reduction: Initiatives focus on combating stigma and discrimination associated with HIV/AIDS, promoting inclusive practices, and protecting the rights of affected individuals.
3. Human Rights and Gender Equality: The program prioritizes the promotion of human rights and gender equality within Armenia's HIV/AIDS response, ensuring equitable access to services and addressing underlying social determinants.

Efforts to raise awareness and promote understanding of HIV/AIDS are integral to the program. Specific campaigns, educational materials, and outreach through social platforms target various demographics, including young people, university students, and specific workplaces. These initiatives aim to foster informed decision-making, encourage preventive behaviors, and support early diagnosis and treatment.

Political declaration and monitoring framework 5. Community leadership

Armenia's HIV response is significantly bolstered by the active involvement of civil society and communities, who play a crucial role in shaping and implementing national strategies. The Ministry of Health (MoH) has embraced community participation through initiatives such as the Transition Plan, developed in collaboration with NGOs, patient communities, and key populations (KPs), alongside international partners like WHO, UNAIDS, and others. This plan focuses on establishing a state social contracting mechanism to increase funding for NGOs delivering preventive services to KPs.

Since 2019, Armenia has adopted a competitive NGO contracting system aimed at ensuring sustainability and transition in HIV-related services. Although provisions for anonymity and data security have been included, full implementation with domestic funding remains pending. In 2023, revisions to HIV prevention and care service packages were made by the HIV working group, aligning with amendments in the National Strategic Plan (NSP).

Community-led monitoring has emerged as a powerful tool to empower communities, ensuring their needs are met and promoting transparency in service delivery and decision-making. The RWRP NGO introduced a community-led monitoring tool in 2022, updated biannually with support from UNAIDS, enhancing advocacy efforts and accountability.

Recent regulatory advancements in Armenia's HIV response include:

1. Maternity and In-Patient Services: Ministerial decrees have expanded access to maternity and in-patient services for pregnant women living with HIV (WLHIV), enabling care provision at any third-level maternity hospital in the country, not limited to the Republican Center of Perinatology and OB/Gyn.
2. Health Personnel Ethical Norms: Ethical norms ensuring non-discrimination towards patients were formalized through a government decree, complemented by the establishment of an Ethics Committee at the Ministry of Health in 2023 to address non-compliance cases.
3. Provision of HIV Care and Services: Amendments to the state standard for HIV care, effective from early 2024, now ensure free access to post-exposure prophylaxis (PEP) for all individuals regardless of nationality or citizenship. Additionally, state funding now supports free access to pre-exposure prophylaxis (PrEP) for up to 100 beneficiaries, replacing previous payment requirements covered by international donor funding.

These regulatory enhancements underscore Armenia's commitment to expanding access, reducing discrimination, and improving the quality of HIV services through inclusive policies and community-driven initiatives.

Political declaration and monitoring framework 6. Realize human rights and eliminate stigma and discrimination

Armenia is actively advancing human rights and combating stigma and discrimination in its HIV response, supported by comprehensive initiatives and partnerships with international organizations.

The National Institute of Health (NIH), in collaboration with UNAIDS, offer online HIV Continuous Education courses for healthcare providers, covering HIV, self-testing, stigma, discrimination, and human rights. Programs now include modules on stigma and discrimination. Since 2022, UNAIDS has focused on educating and empowering women who use drugs and women living with HIV on gender-based violence and support services. This includes disseminating information through booklets, videos, survivor stories, and Living Library initiatives across three cities in Armenia.

In 2022, UNAIDS trained 109 social workers, psychologists, and staff of GBV shelters. In 2023, 600 social workers from Armenia's unified social service (USS) in all 11 regions received training. A manual developed with UNAIDS support on working with people living with HIV (PLHIV) and people who inject drugs (PWIDs) was piloted at Yerevan State University and Yerevan State Pedagogical University. The final revised version has been distributed to universities and the Ministry of Education to strengthen the capacity of future social work professionals.

The Democracy Development Foundation (DDF), supported by the Open Society Foundations, promotes social justice and equitable access to essential social services, with a particular focus on public health. DDF adopts a human rights-based approach and strives for equal healthcare access under universal health coverage. They work collaboratively with professional groups and NGOs to combat inequalities, prejudices, and discriminatory practices in Armenia. Several prominent NGOs in Armenia are actively involved in advocacy efforts to promote human rights and combat stigma. They conduct surveys and implements projects focusing on accountability, women's leadership, and innovative HIV detection and care for PWIDs. Efforts funded by the regional SoS grant aim to assess and improve national protocols for PrEP, HIV testing, and treatment. The grant also supports initiatives to enhance healthcare access for migrants, conduct Stigma Index assessments, and strengthen community-led monitoring (CLM) through REAct. These initiatives will continue under SoS 2.0 in 2024, aiming to promote human rights and reduce stigma and discrimination in Armenia's response to HIV.

Political declaration and monitoring framework 7. Universal health coverage and integration

Armenia is actively pursuing Universal Health Coverage (UHC) to enhance population health outcomes by addressing financial barriers to essential health services and improving care quality. However, significant challenges remain in achieving these goals, including the need to enhance equity in financial contributions and to reorient health financing and service delivery towards Primary Health Care (PHC).

According to WHO estimates for 2021, Armenia's UHC Service Coverage Index was 68, below regional and income group averages (81 for Europe and Central Asia, 79 for upper middle-income countries). The health system performance is hampered by low government health expenditures and high out-of-pocket (OOP) payments, which accounted for 78.7% of total health spending in 2021, far exceeding the average for upper middle-income countries (44.1%). Insufficient government-funded coverage for essential health services contributes to this high OOP expenditure.

The Ministry of Health, acting through the State Health Agency (SHA), serves as the sole purchaser and single payer for medical services covered under the Basic Benefits Package (BBP). However, both service and population coverage under the BBP remain inadequate. Although there are three health benefit packages, only 38% of the population currently enjoys comprehensive coverage for inpatient care, outpatient services, medicines, and diagnostics.

Armenia's health sector reforms are centered around the introduction of Universal Health Insurance (UHI), with plans for legislation adoption in 2024 and implementation starting in 2025. This initiative aims to expand coverage and improve access to healthcare services across the country.

The influx of displaced persons from Karabakh since October 2023 poses additional challenges to Armenia's health system. There is concern that this displacement may impact the epidemiological situations of tuberculosis (TB) and HIV. Many refugees require medical and psychosocial assistance, with mental health support identified as a critical priority by the government. However, the dispersed nature of refugees across Armenia's provinces (marzes) complicates access to and coverage by essential healthcare services. Approximately 30% of the refugee population (over 30,000 individuals) are not registered in the national e-health information system (ARMED), limiting their access to services provided by public institutions.

Addressing these challenges will require concerted efforts to strengthen health system resilience, expand healthcare coverage, and ensure equitable access to essential services, particularly amidst ongoing health and social crises.

Political declaration and monitoring framework 8. Investments and resources

The Government of Armenia remains steadfast in prioritizing its response to HIV/AIDS as a cornerstone of public health protection and improvement. Despite facing challenges such as disruptions caused by the COVID-19 pandemic from 2020 to 2021, geopolitical uncertainties, and currency fluctuations from 2022 to 2023, Armenia is committed to ensuring accessible, high-quality prevention, treatment, care, and support services for people living with HIV and key populations at risk. These efforts are critical for enhancing health system resilience and expanding financial commitments toward sustainable HIV responses, including transitioning essential programs to domestic funding.

Starting in 2024, the Ministry of Health has pledged to cover 100% of Armenia's needs for antiretroviral (ARV) drugs and 40% of the requirements for ARV diagnostic tests. This initiative represents a significant step toward ensuring continuous access to essential HIV/AIDS medications and diagnostic capabilities throughout the country.

While Armenia accelerates its efforts toward domestic funding sustainability, it continues to value international partnerships and acknowledges the crucial role of the Global Fund (GF). Support from international partners, including UNAIDS, remains instrumental in facilitating various research, educational, and support programs. These collaborations also play a pivotal role in advocacy efforts and community empowerment initiatives within the LGBT community, as well as supporting harm reduction programs implemented by international organizations.

These concerted efforts underscore Armenia's commitment to advancing its HIV/AIDS agenda despite multifaceted challenges. Armenia aims to achieve sustainable health outcomes and ensure equitable access to comprehensive HIV services nationwide through a combination of robust domestic initiatives and strategic international partnerships, including continued collaboration with the Global Fund and other key donors.