The most recent developments in the field of HIV treatment suggests that as of January, 2010 the medicines used in treatment were included in the list of compensation medicines.  Within the new compensation system a price is set as negotiated with pharmaceutical companies and is generally lower (3rd lowest in EU) than that paid by tendering the medicines in previous years.
The new system sets that patients are prescribed a recipe for receiving their medicines once a month in a drug store of their choice, while for the patients with good adherence a recipe can be prescribed once every three months.  Moreover, the system at the moment is slowly changing towards a more decentralized approach, e.g. the treatment regimen still can be set only by the council at the LIC, while medicines can be prescribed by the infectious diseases specialist throughout the country (available in major cities at the moment) once a month.  Moreover, negotiations with general practitioners have started so that GPs can prescribe medicines making treatment more accessible throughout the country.  Major problems in making system more decentralized as seen by the people interviewed:
Lack of specialists throughout the country; (interviews at LIC)
reluctance and unwillingness of involvement in HIV treatment from the GPs; (LIC & NGOs)
lack of political will (?) to include NGOs in the treatment provision or referral schemes; (NGOs)
lack of professional and competent discussions towards increasing coverage and availability of treatment (int.org.)
Universal Access
HIV epidemic in Latvia is the major concern and mostly concentrated among IDUs – in recent years some shift towards more general route of infection can be noticed, but still it is concentrated among drug users and their sex partners.
Policy documents (e.g. HIV State Programme 2009–2013) state that all persons who are eligible should receive ART irrespective of route of transmission.  In reality, until recently drug use was a contraindication for fulfilling eligibility criteria for HIV treatment.  The new pharmacological HIV treatment recommendations developed and revised in 2009 by the Health Economics Centre have disregarded drug use as discriminating factor for receiving treatment (Veselības ekonomikas centrs, 2009).  On the other hand stigmatization and discrimination of drug users among general population as well as among specialists is still high. 
“if [state] is paying for the medicines we can ask the [drug] user to quit drug use, can’t we?.” (HEC)
“waste of money to invest in people who abuse alcohol or drugs” (HEC)
“on paper we have removed these lines but do you think the situation has changed in reality?”  (UNODC)
Medium-term strategy of the Latvian Infectology Centre 2005–2009 state that within existing funding ART treatment for the period allows treatment of 250 persons, while with additional funding up to 470 persons can be treated (Veselības ministrija, 2005).
This is what NGOs and international organizations see as one of the major obstacles in reaching UA goals set by the government – on one hand legislative documents state ‘treatment as available for everyone in need’, on the other hand – the rules are strict, access and availability of (drug treatment) services are not always client orientated.
New developments in expansion of methadone maintenance treatment in the country suggest that attitudes of the specialists are changing for better.
Centralization of HIV treatment as seen by the team of WHO experts in March, 2009 is another obstacle in reaching Universal Access goals (WHO, 2009).  Such a topic was mentioned by several respondents,
“why [in Latvia] the treatment is seen so complicated that it cannot be carried out elsewhere [than LIC]?” (UNODC)
The largest group of PLHIV and especially those in need for ART in Latvia are injecting drug users who in many cases are non compliant with treatment rules and drop-out of treatment.  Additionally and as treatment specialists stress out “we do not have access to this population”.  Thus approaches in treatment delivery and access to hard-to-reach populations such as drug users or sex workers might benefit by implementation and development of integrated services.  A solution for making ART more available to injecting drug users is
1) integration of drug treatment and HIV/AIDS services
“as new pharmacological drug treatment programs are opening across the country it is a good idea to expand the services available at one place, for example, HIV treatment”
and/or
2) making HIV/AIDS treatment for drug users available at low threshold centres thus overcoming some stigmatization issues for drug users.  Also as suggested by the people interviewed at the moment one of major obstacles is getting people into treatment – the need for referral schemes and work with the patients not to drop out of treatment and take their medicines regularly. 
Another major obstacle as raised by the international organizations as well as during interviews is funding issues as regards ART.  Within the 2010 budget and new system for compensation of HIV medicines sets spending at 1.20 million LVL (2.45 million USD).  The budget was calculated based on 365 patients in ART – what raises concerns is that currently there are 439 patients in treatment that raises caution whether at the end of the year funding will be available for treating all patients.  Additionally three medicines for patients on ‘salvage’ treatment regimens were posted on the C list of compensation medicines – meaning that only a specific number (nine persons) of patients are allowed to be prescribed these medicines.  Thus if additional patients during a year will need any of these medicines problems in prescribing these regimens will arise and according to NGOs and treatment specialists – it is of major concern.
The new HIV treatment recommendations state that “within the limited health care budget possibilities the level of CD4 to initiate treatment is 200 cells/mm3” as compared with WHO recommendations of 350.  In reality and from discussions with PLHIV and NGOs such situation might mean that groups that are not easy to work with as they do not show good adherence and do not take medicines regularly, e.g. IDUs, sex workers, inmates, are kept out of treatment. 
According to expert estimates the number of people that are in need of ART varies quite a lot – as expressed in the interviews with NGO – it differs based on what is counted as a person in need.  According to the NGO working in advocacy the number of persons in acute need for ART who do not receive it is 130, the number of persons who could be eligible for treatment and would benefit from it might be between 1000 and 1500 or “for a small country as Latvia at least one-third of people living with HIV should receive treatment or at least from CD4<500”.  According to the treatment specialists there are around 800 people who need treatment or “ART is received by roughly one-half of persons who need it”.  Some other estimates on the number of people who need treatment but do not receive might be around 700 persons.
Since 2006 a four-year UNODC funded project “HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania”.  The overall goal of the project is to assist Estonia, Latvia and Lithuania to halt and reverse the HIV/AIDS epidemics among injecting drug users and in prison settings. 
Recommendations (to be developed more)
As one of the major obstacles in reaching UA goals mentioned by most of people interviewed is patient non-compliance with treatment regulations and lack of treatment centres to access hard-to-reach populations a solution for development of integrated services, e.g. harm reduction and HIV treatment or drug treatment services with HIV treatment. 
At the national level supporting of NGOs working with hard to reach populations – NGO delivered programmes.
Data collection needs to be expanded.
Based on interviews’ and information available it is difficult to assess how financial situation in the country influences patients’ physical accessibility to treatment, e.g. costs of transportation, etc. but possibly a topic to look into.

Literature
European Centre for Disease Prevention and Control/WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2008. Stockholm: European Centre for Disease Prevention and Control; 2009.
Veselības ekonomikas centrs. Racionālas farmakoterapijas rekomendācijas no valsts budžeta līdzekļiem apmaksātai antiretrovirālai terapijai HIV/AIDS infekcijas ārstēšanai. Rīga: Veselības ekonomikas centrs; 2009.
Latvijas infektoloģijas centrs. HIV infekcijas ārstēšanas vadlīnijas. Rīga: Latvijas Infektoloģijas centrs; 2009.
Cilvēka imūndeficīta vīrusa (HIV) infekcijas izplatības ierobežošanas programma 2009.–2013.gadam
Joncheere K. et al. Evaluation of the Access to the HIV/AIDS Treatment and Care in Latvia. 2009
LR Veselības ministrijas rīkojums ”Par valsts aģentūras „Latvijas Infektoloģijas centrs” vidēja termiņa darbības stratēģiju” 2005.–2009.gadam”” (13.07.2005.)