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HIV in central and eastern Europe
Lancet 2003; 361: 1035-44. Published online Feb 18, 2003
Francoise F Hamers, Angela M Downs
  We describe recent trends in the HIV epidemic and the differences between eastern and central Europe, using surveillance data, and published and unpublished reports. During the past 5 years, most countries of the former Soviet Union have been severely affected by HIV epidemics that continue to spread as a result of injecting drug use. With an estimated 1 million individuals already infected--mostly injecting drug users-and high rates of syphilis, the region may soon also face a large-scale epidemic of sexually-transmitted HIV infection. Indeed, data indicate that an HIV epidemic, fuelled by heterosexual transmission, is emerging; its expansion will depend on the size of so-called bridge populations that link high-risk groups with the general population. The lack of evidence to indicate increased rates of HIV as a result of homosexual transmission could indicate the social vulnerability of homosexual and bisexual men in the region rather than the true epidemiological picture. In view of the current levels of HIV prevalence, eastern Europe will soon be confronted with a major AIDS epidemic. By contrast, rates of HIV in central Europe remain low at present, but behaviours that promote HIV transmission are present in all countries. Improved measures to prevent further HIV spread are urgently needed.
Although initially isolated from the global HIV pandemic by draconian Soviet restrictions on contact with foreigners and harsh social control, there has been a growing epidemic in eastern Europe since the mid 1990s. The first outbreaks were reported in 1995 among injecting drug users in Odessa and Nikolayev in southern Ukraine. They were rapidly followed by other drug-related HIV outbreaks, notably in the Russian territory of Kaliningrad in 1996, and a few months later in other regions of the Russian Federation (Krasnodar, Rostov on Don, Tver) and in neighbouring Belarus and Republic of Moldov. In 1999, two very large outbreaks were identified, again in the Russian Federation, in the Moscow and Irkutsk regions. Since then, the situation has continued to worsen rapidly, affecting more regions and countries. UNAIDS and WHO recently reported that, with an estimated 1 million HIV-positive individuals at the end of 2001 compared with only 30 000 at the start of 1995, eastern Europe and Central Asia are the regions of the world with the fastest growing HIV epidemic. By contrast, in central Europe, epidemics that began in the late 1980s have remained at low levels, apart from specific outbreaks in Romania and Poland, and do not seem to be expanding.
To further understand the development and recent trends of the HIV epidemic in central and eastern Europe, we analysed HIV/AIDS surveillance data for the 27 countries of the former communist bloc, including all countries of the former Soviet Union, some of which are in Central Asia. We also reviewed published and unpublished studies and reports. We then examined the contributions of different vulnerable populations and discussed factors influencing the past increases in rates of HIV infection and the potential for future increases, taking into account the public-health response.
Routes of transmission and risk factors
Injecting drug use
The spread of HIV in the East region is closely linked with a rise in injecting drug use that developed after the collapse of the Soviet Union during the 1990s in the midst of a severe socioeconomic crisis and at the time when Afghanistan became the world’s largest opium producer. This increase in opium production was paralleled by a diversification of trafficking routes through Central Asia and eastern Europe, an increase in overall trafficking of heroin from Afghanistan and surrounding countries to Europe, and a considerable rise in drug consumption. The extent of drug use is hard to assess because of the illicit nature of drug use and the hidden nature of target populations, but all available indicators suggest that abuse continues to rise rapidly. Even fewer data are available on behaviours of drug users, but sharing of injecting materials appears to be widespread, sexual promiscuity is common, and HIV prevention is rarely a priority. In the Russian Federation, for example, 86% of 82 intravenous drug users surveyed in the street in Ekaterinburg in 1998 had shared injection equipment in the past month, whereas in Moscow, among 424 injecting drug users, 35‹41% shared injection equipment and 37‹39% stated that they had never been tested for HIV.
In the Centre region, in Prague, Czech Republic, in 1996, among 611 injecting drug users, 280 (46%) had shared injection equipment in the past 6 months and 423 (69%) had multiple sex partners in the past 12 months.
In the East region, although several specific surveys have recently been initiated at regional or city level, most data for HIV prevalence in injecting drug users come from country-wide diagnostic testing. Since 1999, national prevalence estimates range from 2‹4% in Belarus and Moldova and 5% in the Russian Federation to around 10% in Latvia and in Ukraine. As reported from other parts of the world, HIV prevalence among injecting drug users varies widely between regions and cities within countries, and may vary substantially according to study methods and recruitment sites. In Belarus in 2000, estimates from diagnostic testing data ranged from 1% or less in Vitebsk and Minsk to 7% in Gomel; whereas in the same year, a survey based on testing of residual blood in used syringes returned by 200‹300 clients of needle exchange programmes suggested prevalence levels of 0% in Vitebsk, 22% in Minsk, and up to 66% in Svetlogorsk. The same study method used in Ukraine indicated levels ranging from 18% in Kharkiv to 64% in Odessa in 2000, and in the Russian Federation, a prevalence of 12% in St Petersburg in 1999. Prevalence estimates based on diagnostic testing have decreased substantially in recent years in several countries including Belarus (from 7% in 1996 to 2% in 2000 nationally and from 25% to 7% during the same period in Gomel), Republic of Moldova (1997: 7%; 2000: 3%), and Latvia (1999: 15%; 2000: 9%). However, these trends probably reflect increasing participation bias over time due to progressive exclusion of known HIV-positive individuals from the tested population, rather than true decreases in prevalence.
In the East region, HIV epidemics have been developing through injecting drug use for over 5 years and have spread progressively throughout the region. HIV prevention among injecting drug users should therefore be the cornerstone of regional and national prevention strategies.10 Although harm reduction programmes have been set up in several countries, their coverage (10% of injecting drug users had been in contact with needle exchange programmes by 2000) remains too low to significantly affect the evolution of the epidemic.
With an estimated 1 million infected individuals, mostly injecting drug users, and high rates of syphilis resulting from risky sexual behaviour, which also enhances the risk of HIV transmission, the East region seems on the verge of a major sexual epidemic of HIV. The recent increase in reported numbers of heterosexually acquired HIV infection and the shift in transmission pattern from injecting drug use to heterosexual contact indicate that a heterosexual HIV epidemic is already emerging. The rate of its expansion will depend essentially on the size of so-called bridge population groups that link high risk groups (in this case, injecting drug users) with the general population. Data from western Europe show that the countries with the most severe HIV epidemics among injecting drug users (Portugal, Spain) are also those with the highest rates of heterosexually acquired HIV, suggesting spill-over of HIV across subpopulations. The lack of evidence of homosexual spread of HIV in the East region could reflect the social vulnerability of homosexual and bisexual men in the region rather than the true epidemiological picture in this population.
Prevention of sexual spread should not wait for higher prevalence levels and should concentrate on key population subgroups that, because of their heightened behavioural risks, merit immediate attention in terms of HIV prevention. These include homosexual and bisexual men, prostitutes and their clients, individuals with other sexually transmitted infections, and adolescents. To be effective, the public-health response to HIV will have to create the social, legal, and ethical environment that is conducive to HIV prevention, care, and support. HIV prevention interventions for men who have sex with men will need to be tailored to the situation including the high frequency of bisexual behaviour and the lack of community experience in HIV prevention.
The safety of the blood supply in the region is another matter of concern, and improvements in donor selection should become an urgent priority. Ensuring blood safety is one of the most cost-effective and non-controversial HIV prevention interventions.
With current HIV prevalence levels, the East region will soon be confronted with a major AIDS epidemic and thousands of people will need care in countries in which the health-care system has basically collapsed. It is also likely that HIV will have a strong negative impact on tuberculosis control in this part of the world in which the prevalence of tuberculosis, including that of multidrug resistant strains, is high and in which both infections, tuberculosis and HIV, are concentrated in the same, young, disenfranchised populations.
The dramatic situation in the East region should not be allowed to lead to complacency in the Centre region. There is a danger that the label of low prevalence may translate to low priority for HIV prevention. In Romania, there is a large surviving cohort of HIV-infected adolescents, contaminated in their childhood and now frequently homeless, who may soon start to engage in behaviours that put them at risk of transmitting HIV to others. Economically motivated migration from affected countries of the East region to central and western Europe is a further cause of concern. Targeted, non-discriminatory prevention programmes and the promotion of voluntary counselling and testing within migrant communities should become urgent priorities.
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