VZCZCXRO7485
RR RUEHAG RUEHAST RUEHBI RUEHCI RUEHDBU RUEHDF RUEHIK RUEHLH RUEHLN
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DE RUEHAH #0629/01 1390348
ZNR UUUUU ZZH
R 190348Z MAY 09
FM AMEMBASSY ASHGABAT
TO RUEHC/SECSTATE WASHDC 2836
INFO RUCNCIS/CIS COLLECTIVE
RUCNMEM/EU MEMBER STATES COLLECTIVE
RUCNCLS/ALL SOUTH AND CENTRAL ASIA COLLECTIVE
RUEHAK/AMEMBASSY ANKARA 5206
RUEHBJ/AMEMBASSY BEIJING 2947
RUEHKO/AMEMBASSY TOKYO 2812
RUEHIT/AMCONSUL ISTANBUL 3450
RHMFIUU/CDR USCENTCOM MACDILL AFB FL
RHEHNSC/NSC WASHDC
RUEAIIA/CIA WASHDC
RHEFDIA/DIA WASHDC
RUEKJCS/JOINT STAFF WASHDC
RUEKJCS/SECDEF WASHDC

UNCLAS SECTION 01 OF 03 ASHGABAT 000629 
 
SIPDIS 
 
SENSITIVE 
 
STATE FOR SCA/CEN, EUR/ACE, F, OES/IHB 
AID/W FOR EE/EA 
 
E.O. 12958: N/A 
TAGS: PGOV PREL EAID EINV TBIO SOCI KZ
 
SUBJECT:  TURKMENISTAN: FIGHTING TUBERCULOSIS IN THE ISOLATED 
COUNTRY IS AN UPHILL BATTLE 
 
¶1.  (U) Sensitive but unclassified.  Not for public Internet. 
 
¶2.  (SBU) SUMMARY: Recently thought of as a disease of the turn of 
the last century, tuberculosis (TB) has once again reared its ugly 
head.  While, in modern times, TB is mostly associated with HIV 
infection in developing countries, in the former Soviet republics of 
Central Asia, TB is a disease to be reckoned with in its own right. 
The collapse of the Soviet Union and its complex health system has 
helped to create this new epidemic.  And, a deadlier form of the 
disease -- drug-resistant TB -- has emerged, and poses an increasing 
threat to the region.  Turkmenistan, which has isolated itself since 
independence in 1991, is at further risk, as the government 
continues to refuse to publicize accurate health data (including the 
existence of HIV in Turkmenistan).  END SUMMARY 
 
TUBERCULOSIS IN TURKMENISTAN 
 
¶3.  (SBU) Turkmenistan's TB epidemic, compounded by a hidden HIV 
threat, could cast a long shadow over Turkmenistan's future.  TB 
presents a major challenge to the country's healthcare system and to 
its economic development via decreased workforce productivity.  In 
line with its erstwhile Soviet neighbors, Turkmenistan suffers from 
one of the world's highest recorded rates of TB.  According to the 
World Health Organization's (WHO) latest figures, 68 per 100,000 
Turkmenistanis have TB, as opposed to six per 100,000 in the United 
States.  In terms of annual TB incidence, Turkmenistan ranks ninth 
highest in the WHO's "European" region, which comprises 53 
countries. 
 
DRUG-RESISTANT TB: AN EMERGING, DEADLIER THREAT 
 
¶4.  (SBU) Further exacerbating the epidemic is the emergence of 
"multi-drug-resistant" (MDR) TB: TB that is resistant to at least 
one of the "first line" -- or standard antibiotics -- used to treat 
TB.  Until this year, the only available data regarding drug 
resistance in Turkmenistan was from a small survey conducted in 1999 
that reported four percent of newly-diagnosed TB cases were drug 
resistant, and 18 percent of TB patients who had relapsed -- 
otherwise referred to as "chronic" TB cases -- had a drug-resistant 
form of TB.  However, this year, new data has come to light.  In a 
study carried out by the Government of Turkmenistan of 243 TB 
patients in the Ashgabat TB hospital, 21 percent of new TB cases 
were identified as drug-resistant cases, and 34 percent of chronic 
cases had drug-resistant TB.  Therefore, over one quarter of all TB 
cases had MDR TB: a frightening statistic if it were to represent 
the national situation. 
 
CHALLENGES IN TREATMENT EXACERBATED BY DRUG RESISTANCE 
 
¶5.  (SBU) Factors that contribute to the spread of MDR TB include 
incorrect prescription for treatment, incomplete treatment caused by 
interruptions in drug supply or poor adherence to grueling treatment 
protocols, and poor infection control in TB and penitentiary 
facilities. 
 
¶6.  (SBU) When TB is responsive to first-line drugs, patients face 
treatment regimens lasting between six and 12 months with a standard 
course of antibiotics that are affordable ($40 per patient) and 
readily available.  However, to cure drug resistant TB, the patient 
must undergo two years of treatment with a more complex regimen of 
drugs that are much more expensive than first-line TB drugs.  The 
treatment regimen for MDR TB can be debilitating -- not just due to 
the duration of treatment, but also to the side effects caused by 
the more sophisticated antibiotics.  Further, all who are infected 
by a drug-resistant TB carrier also acquire a resistant form of the 
infection. 
 
WHO IS AT RISK? 
 
¶7.  (SBU) Populations most at risk of becoming infected with TB or 
MDR TB in Turkmenistan are all who come into regular contact with 
those who are infected: prisoners, penitentiary workers, health 
providers, families of those with active TB, injecting drug users, 
 
ASHGABAT 00000629  002 OF 003 
 
 
and people living with HIV. 
 
...BUT HIV DOES NOT OFFICIALLY EXIST IN TURKMENISTAN 
 
¶8.  (SBU) TB is the leading cause of death among HIV patients 
worldwide.  However, while Turkmenistan does have a National AIDS 
Center in its capital and supports HIV "prevention centers" 
nationwide, the government refuses to publicize HIV data, and 
instead insists that HIV does not exist in Turkmenistan. 
 
¶9.  (SBU) Shortly after HIV became a pandemic, in 1991, the 
administration of then-President Saparmurat Niyazov created an 
HIV/AIDS system under its Ministry of Health.  However, President 
Niyazov was informed that HIV was spread by prostitution and men who 
have sex with men, acts which are illegal in Turkmenistan.  Some 
feel that admission of HIV prevalence would have therefore promoted 
Niyazov's perception that his government was not able to enforce 
certain laws. 
 
¶10.  (SBU) Niyazov died in December 2006, and was succeeded by the 
Minister of Healthcare and Medical Industry, Gurbanguly 
Berdimuhamedov, in February 2007.  While President Berdimuhamedov 
has continued to welcome international assistance for Turkmenistan's 
health system, the government has yet to publicly recognize that any 
of its citizens are infected with HIV. 
 
VERTICAL STRUCTURES OF CARE: A VESTIGE OF THE SOVIET ERA 
 
¶11.  (SBU) A legacy of Soviet times, Turkmenistan's healthcare 
system relies on many "vertical structures" -- that is, highly 
independent, stand-alone systems charged with diagnosing and 
treating specific diseases or conditions.  The TB, HIV/AIDS, and 
primary healthcare systems are typical vertical structures, each 
operating separate databases and using different protocols that 
allow for little interaction or collaboration with one other.  These 
vertical structures, coupled with the country's insistence that HIV 
does not exist, present a major obstacle for TB patients in need of 
HIV diagnosis, counselling, and treatment, and vice-versa for those 
infected with HIV. 
 
¶12.  (SBU) The penitentiary system, which falls under the Ministry 
of Internal Affairs, has yet another vertical healthcare structure 
that is not connected to the civil healthcare system, presenting 
problems for newly-released prisoners.  And, similar to other 
countries in the region, TB is an acute problem in prisons.  The 
World Health Organization estimates that TB prevalence in 
Turkmenistan prisons is 65 times higher than the national level. 
 
TURKMENISTAN'S RESPONSE 
 
¶13.  (SBU) In 1999, Turkmenistan adopted the "DOTS" strategy, the 
internationally-recognized approach to controlling TB.  Eight years 
later, Turkmenistan reported 100% DOTS coverage in the civilian 
healthcare system, and the penitentiary healthcare system began 
implementing DOTS in June 2008.  This "success" is deceptive as the 
quality of DOTS implementation is questionable.  Officially reported 
data yield good detection rates and treatment-success rates, 
although the recent drug resistance survey in the Ashgabat TB 
hospital tells a different story.  Although the Government has 
drafted a number of TB-control decrees (e.g. the 2005-2009 National 
TB Control Program Plan, and the 2008-2015 National Strategy to 
Prevent and Control TB), there remains a dearth of specialists who 
can interpret and analyze data, conduct operational research, test 
interventions, design evidence-based action plans, and monitor 
impact. 
 
¶14.  (SBU) Turkmenistan publicly reports that none of its TB 
treatment facilities are administering MDR TB treatment.  However, 
despite shortages of trained TB specialists and inadequate technical 
capacity to treat MDR TB, the Government of Turkmenistan has 
purchased MDR TB drugs and began treating MDR TB patients in the 
Ashgabat TB hospital in January 2009.  To guard against resistance 
to MDR TB drugs, it is imperative to ensure that TB medical staff 
 
ASHGABAT 00000629  003 OF 003 
 
 
are well-trained to diagnose and monitor treatment and that 
adherence during the two-year regimen is strictly followed. 
Otherwise, Turkmenistan risks becoming an epicenter of 
extensively-drug-resistant TB, for which there is no known cure. 
 
¶15.  (SBU) In concert with the WHO and Doctors without Borders, 
which have operated in Turkmenistan since 1999, the U.S. Government 
-- through USAID -- has responded by providing support to 
Turkmenistan's national TB program since 2000.  Activities have 
focused on: providing training to improve diagnosis and treatment 
for those infected with TB; upgrading laboratories with modern 
equipment to better detect TB; securing WHO-approved first-line 
drugs to treat "normal" TB; and, developing and publishing a new TB 
textbook to be used in Turkmenistan's medical education system. 
 
THE WAY FORWARD 
 
¶16.  (SBU) Some efforts have demonstrated progress in the fight to 
control TB, such as updating laboratories' equipment and enhancing 
their capacity to correctly diagnose the infection.  However, given 
the high rate of TB, the emergence of MDR TB, and an unknown 
prevalence of TB/HIV co-infection, it is clear that much more needs 
to be done to prevent the further spread of TB in Turkmenistan. 
 
¶17.  (SBU) Under the leadership of President Berdimuhamedov, 
Turkmenistan is showing signs of slowly-but-surely opening up to the 
wider world.  In 2008, Turkmenistan put forth an application for TB 
funding from the Global Fund to Fight AIDS, TB & Malaria, which was 
not approved.  However, the country intends to submit an improved 
application, valued at $17.3 million over five years, to the Global 
Fund's Ninth Round by June 1, 2009.  Should Turkmenistan's 
application be approved, it will provide an incentive for 
authorities to further open the door to the international arena, 
which will afford Turkmenistan's health systems greater access to 
international standards and arm it with the tools to mitigate the 
growing threat of TB. 
 
MILES 
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