The western Balkans includes Bosnia and Herzegovina, Serbia and Montenegro, Kosovo, Albania, and Macedonia. Official estimates suggest the prevalence of HIV infection is low (ranging from 47 cases in Kosovo to 1767 in Serbia by December 2003) and that the infection is primarily sexually transmitted, except in Serbia where drug injecting is the main route.
12 Although the Balkan HIV epidemic is different from that of eastern Europe, the risk environment has similarities, including widespread poverty; mass unemployment and social insecurity; increasing human, drugs, and sex trafficking; migration associated with economic hardship and civil strife; and transitions from command economies to open markets associated with drastic reductions in health and welfare provision as well as new sex and drug markets.
The effect of conflict on vulnerability to HIV infection in the region is under-researched. Armed and ethnic conflicts have affected large sections of the Balkan population, many of whom have been displaced. In Serbia, a quarter of some city populations are internally displaced people, and there are around 700 000 refugees and displaced people in a population of 8 million.
13 Over 500 000 people in Bosnia and Herzegovina and 300 000 in Kosovo are displaced.
12 Population displacement is linked with lack of access to food, shelter, and health care.
14 Refugee collection centres often lack sanitation. Some are associated with sexual violence or abuse.
Regional conflicts have intersected with economic and political transition. The Yugoslavian conflicts shifted Serbia and Montenegro from a medium developed to an underdeveloped nation.
15 International sanctions reportedly created “universal compulsory poverty,” trapping whole social groups on state subsidies while forcing the most able into illegal economies, including human and drug trafficking.
16 In 2002, the income of over half of the Serbian population was insufficient to meet basic needs.
17 Economic decline in the region displaced educated economically active young people abroad. During the 1992-5 war in Bosnia, nearly half of all health workers left the country. Attendance at medical school fell by half, weakening capacity in health expertise.
18Sex inequalities have become particularly visible. Refugees and displaced people are often women or children whose host countries are also compromised in relation to HIV vulnerability and human rights.
10 People changed sexual partner more frequently during the conflicts,
19 and sex work is also linked with human trafficking in a weakening labour market. Rape was used as a weapon against ethnic populations, with 50 000 women reportedly raped in Bosnia and Herzegovina and Croatia.
20 Drug use also increased in the region, associated with psychological trauma from experiencing war and perceived loss of life opportunity.
19,21Regional conflicts connected with a history of nationalism and reproduced a culture of governance that discriminated against diversity.
22 This has fed intolerance towards social groups that do not meet a national ideal. Populations of Roma, men who have sex with men, people with HIV and AIDS, refugees, and displaced people face multiple vulnerability. In Serbia, 40% of registered Roma live in refugee centres; they rarely have legal employment, lack access to public services, and often lack citizenship rights.
23 Prejudice within medical communities towards men who have sex with men and people with HIV infection discourages them from seeking help
12 and limits capacity to prevent the spread of HIV.
10As in Russia, the public health response in Balkan countries is vulnerable. The development of national strategies for preventing HIV infection has been displaced by other welfare pressures. In Kosovo, Albanians were deprived of health treatment and feared mistreatment in the Serb-run hospitals of Pristina.
24 In parts of Bosnia, the rebuilding of health care became a site for nationalistic stalemate, with all parties being obstructive.
25 The ageing health services face chronic shortage of medical equipment and medicines (including HIV test kits), increasing reliance on private pharmacies and health care, cuts in spending, and administrative upheaval in reorienting to new national boarders. The non-government sector is embryonic, especially for HIV and AIDS. HIV prevention comprises small pilot projects with short term funding. Investment in epidemiology and surveillance stalled during transition. Consequently, surveillance of HIV and AIDS can be unreliable, making the detection of HIV outbreaks difficult.
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