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(Editor’s note: Tatiana Shoumilina, project coordinator for UNAIDS in Moscow, discussed the HIV epidemic’s toll on Russia with AIDS Alert shortly after UNAIDS released its most recent statistics, showing that HIV cases have skyrocketed in Eastern Europe and particularly in Russia. Shoumilina’s responses to this Q&A came via the Internet in late December.)
AIDS Alert: The 2000 UNAIDS report says the Eastern European AIDS epidemic is fueled primarily by injection drug use. Are you currently seeing evidence that the epidemic is spreading to heterosexual and pediatric populations, and, if so, how bad is that problem?
Shoumilina: Yes, there is such evidence. Experts say sexual transmission of HIV in Russia is on a steep rise, especially in the Russian regions that have been experiencing outbreaks of the epidemic since 1996. The patterns and dynamics of the HIV epidemic emergence in different regions of the Russian Federation are more or less uniform, with initial outbreaks of HIV among injecting drug users (IDUs) followed by increasing incidence of sexual transmission. For instance, in the Kaliningrad Region, sexual transmission of HIV constituted 32% of newly detected cases in 2000, vs. 3% in 1996. In the Rostov-on-Don Region, sexual transmissions of HIV reached 37.8% in 2000.
The number of children born to HIV-infected mothers is steadily growing. Though the absolute figure — 406, as of Nov. 1, 2000 — is not high, the dynamics show geometrical progression. Thirty-eight cases of mother-to-child transmission (MTCT) of HIV were detected in 1997, 71 cases were detected in 1998, and 178 MTCT cases were found in 1999. A majority of those mothers are injecting drug users who often reject their children.
AIDS Alert: UNAIDS has discussed the problem of injection drug use and HIV infections in Russia for the past couple of years. Has the Russian government or any of the neighboring nations tried needle-exchange programs or similar measures?
Shoumilina: You know most probably that Russian legislation relating to illicit drug use is not prepared to face the reality of the HIV epidemic. The existing legislation does not provide either for needle exchange or substitution therapy programs. The law enforcement bodies, in particular the Ministry of Interior and the Prosecutor’s Office, initially were very strongly opposed to those law-violating measures. At present, the Ministry of Interior insists on the respective changes of the legislation so that practices do not contradict the law.
The first pilot needle-exchange programs were implemented in Russia starting in 1997. The international community has played and continues to play an important role in introducing the programs in Russia. Projects dealing with HIV prevention among IDUs, including harm reduction projects, are carried out in 30 regions of the Russian Federation. State institutions and nongovernmental organizations are implementing these initiatives in close collaboration. The Federal Ministry of Health and the regional authorities are supportive and encourage implementation of the initiatives. A few Russian regions, such as St. Petersburg (F.C.), the Astrakhan, Nizhny Novgorod, Tomsk and Tyumen Regions, and the Altai Territory are ready to pilot opioid agonist substitution therapy programs.
AIDS Alert: What type of treatment is available in Russia for HIV/AIDS patients? What are their major challenges to providing adequate testing, treatment, and prevention education?
Shoumilina: Upon testing positive, a person is expected to register with a territorial AIDS Centre, which is a public health institution, and receive follow-up care. Though the general policy is that all public health facilities should provide medical help — not related to their HIV status — in practice there is the risk of discrimination against people living with HIV/AIDS in accessing health services.
Currently, specialized care for people living with HIV is limited to a select number of specialized centers. According to Russian law, the state bears all expenses related to treatment . . . and these expenses are covered from the regional budgets. As the public health budget is very limited, the public health institutions of the regions are unable to provide the full range of necessary medications.
In this case, patients’ access to free drugs for the treatment of opportunistic infections or free antiretrovirals is limited. Provided that there are indications for antiretroviral therapy, the patient’s consent, and funds available, combined specialized treatment will include 2 or 3 antiretroviral drugs, a majority of which are imported from the USA, Switzerland, France, and Great Britain, and are very expensive. Antiretroviral monotherapy is not recommended. As a rule, injecting drug users do not receive antiretroviral therapy, as they are not able to strictly follow the medication schedule.
According to the findings of the UNAIDS- supported strategic planning process, the main challenges or core factors hindering the effective response to the HIV epidemic in Russia are as follows:
1. insufficient political and public awareness of the fast development of the HIV epidemic and its threat to national security and development in the short-term and long-term perspective;
2. lack of HIV-related national policy addressing HIV/AIDS as a complex social issue, which demands multisectoral approach and cooperation of all state, nongovernmental, private, and international actors;
3. lack of professional knowledge about HIV transmission and prevention on the part of many medical professionals and the majority of non-medical specialists dealing with HIV/AIDS-related social areas;
4. unsafe attitudes toward health and health protection remaining as a legacy from Soviet times;
5. lack of funds.
AIDS Alert: What age groups are primarily being affected by the epidemic in Russia, and what are the prevalence rates of the various age groups and genders?
Shoumilina: To date, the majority of HIV infections have been among males. While at the early stages of the epidemic the male/female ratio within the HIV-infected population was 4:1, at present the newly detected cases show it is 2:1. Increasing injecting drug use among women and sexual transmission of HIV, particularly among sexual partners of IDUs, has influenced the change in this ratio. The majority of newly detected HIV cases is among young people under the age of 25 years, with the proportion of younger age groups fast increasing. The highest prevalence is still in the age group 20-40 years, although the incidence is highest among the 17-23 age group. A total of 1,051 cases are registered in children under 15.
As of July 1, 2000, the cumulative number of registered HIV cases in Russia constituted 50,628, and of them, 39,516 were in men and 11,112 were women. A total of 925 cases were detected in children under age 15, with 11,201 in young people of the age group of 15-20 years; 30,159 HIV infections were detected in the 20-30 age group.
AIDS Alert: Why should the rest of the world be concerned about the HIV epidemic in Eastern Europe, and how is UNAIDS addressing those concerns?
Shoumilina: As infectious diseases — and AIDS as one of four leading killers — represent a serious threat to global security, it is important that the response to the threat is also global. As far as the countries in transition are concerned, the full-scale epidemic will enormously stretch the economy of such countries, and they will be much less able to effectively mitigate the epidemic’s impact.
Prevention of the full-scale epidemic is the only cost-effective response to the spread of the disease in countries which are not yet badly affected by HIV/AIDS. Strategic planning of the response to HIV/AIDS in the countries of Eastern Europe is one of UNAIDS’ priorities in the region. The Russian Federation has just completed the strategic planning exercise supported by UNAIDS. The Joint Response to the HIV/AIDS Epidemic Initiative that addresses the proposed strategic priorities was introduced to the international donor community on Nov. 16, 2000. Similar processes were supported in other countries of the region.
One of the strategic priorities is the establishment of the high-level National Committee on HIV/AIDS in the Russian Federation. UNAIDS will support this activity through its Programme Acceleration Funds.