Executive Summary

In September 2006 a Rapid Assessment and Response (RAR) addressing drug use and HIV/AIDS in Mongolia commissioned by the World Health Organisation Regional Office for the Western Pacific was conducted by a team from the Program of International Research and Training (PIRT) of the Australian National Drug and Alcohol Research Centre (NDARC). WHO RAR Guidelines were followed. Four members of PIRT spent a total of 59 person-days in country conducting research activities and writing this report.

The HIV epidemic is still at a very early stage in Mongolia. However, Mongolia faces the threat of a future HIV epidemic and its potentially serious health, social and economic costs and risks to national security. Few HIV infections have been reported to date but the number of HIV infections is likely to far exceed the number of reported infections.

Currently there is little injecting of illicit drugs in Mongolia and to date there have been no reported cases of HIV transmission occurring through injecting drug use. At present sexual transmission of HIV between clients and commercial sex workers (CSWs) and also among and from men who have sex with men (MSM) appear to be the most likely pathways that could result in HIV then spreading extensively to the general population during the next decade.

Less critical risk groups and practices at the moment include: (i) heterosexual men and women, including especially mobile populations and migrant mining communities; (ii) medical injecting and skin penetration including in both the formal and informal (traditional) health care sectors and mainly involving patients prescribed morphine who inject themselves intra-venously frequently and for many years; and (iii) illicit injecting drug users. Street children (especially girls who may be at risk of becoming engaged in CSW) are also at risk. The high prevalence of hepatitis C, 16%-24% by some estimates, suggests that there is considerable use of used injecting and other skin penetration equipment in the health care and para-medical systems.

Two of the five countries (China, Russia) in the world with the most rapidly increasing HIV epidemics are Mongolia’s neighbours. This is of great concern. Unlike almost all other countries in Europe and Asia, there is little evidence so far of injecting drug use that has diffused through almost every other country in South East, South and East Asia in recent decades. Mongolia’s isolation, accentuated by the harsh seasonal factors, sparse population, and current limited road, rail and air travel may have protected the country from the spread of injecting drug use till now. However, the high proportion of young people, high levels of youth unemployment, improving communications infrastructure and newly emerging pockets of affluence may herald rapidly increasing illicit drug use,
including injecting drug use.

In a number of countries, HIV has spread rapidly among and from injecting drug users in community and prison settings. In some of these countries, initial HIV spread among injecting drug users has precipitated generalised epidemics. Mongolia is currently illprepared for this possibility.

The Government of Mongolia appears to be well aware of the potential seriousness of the threat of HIV and has a high level commitment to keeping HIV under control. This report recommends that the Government of Mongolia adopt a comprehensive approach to the threat of HIV/AIDS including:

Raising and maintaining high levels of awareness among the community of the risks of HIV;
Achieving improved results from the 100% condom utilisation programme in the commercial sex industry by implementing this programme throughout the country as rapidly as possible;
Strengthening STI policy and practice as a matter of urgency so that STIs in Mongolia are brought under control as soon as possible;
Promoting condom use in the general community;
Encouraging increased use of voluntary counselling and testing, especially among target groups including MSM, CSWs and emerging IDU populations;
Protecting the human rights and reducing the stigma experienced by target populations to facilitate more accessible and better services for these groups and reduce their engagement in HIV risk behaviours;
Reducing the re-use of un-sterile injecting equipment in the formal and informal health care systems;
Increasing the provision of non-judgemental, evidence based drug education in schools and in the community;
Increasing the capacity, expanding the range of options, and improving the quality of drug treatment by basing treatment on evidence and increasing funding.

Many of the recommendations will benefit not only HIV prevention but will also assist in controlling STIs and reduce drug use.

It is critical for Mongolia that the current low prevalence of HIV in the country is maintained as long as possible and that epidemic spread is averted. Early and vigorous action will avoid an HIV epidemic in Mongolia. As in other countries that have managed the HIV epidemic well, this will require strong political leadership and effective collaboration between health and justice ministries. The cost of action may seem rather high now but this will not compare with the much higher future cost of inaction.