The fastest-growing epidemic in the world
HIV/AIDS in Eastern Europe
Von Manfred Zahorka / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Eastern Europe and Central Asia were largely unaffected by HIV/AIDS up to the early 1990s. As recently as 1994, no country in this region was reporting more than a few HIV infections, with an estimated total of 30,000 infections. A first outbreak with rapid increase in registered cases started a year later mainly in Ukraine, Belarus and the Russian Federation. Since then the situation has dramatically changed. In only two years time the number of infected people has increased more than five-fold with a rapid increase in the incidence (1) of the disease. With an HIV/AIDS prevalence (2) of up to 1% of the general population (Ukraine) the region is currently not experiencing a situation like the one prevailing in some African or South-East Asian countries. The alarming sign however is the dramatic increase of the incidence, the number of new cases per year. The region is now experiencing the fastest-growing epidemic in the world.
Approximately one million people in Eastern Europe and Central Asia are currently living with HIV/AIDS, which is more than double the number found at the end of 1999 (420,000). New cases of HIV have been almost doubling annually for several years in the Russian Federation. The total number of HIV infections reported since the epidemic began now stands at more than 173,000 cases - up from the 10,993 reported at the end of 1998. HIV spread is now also evident in Azerbaijan, Georgia, Kyrgyzstan, Tajikistan and Uzbekistan. The change in testing procedures from mandatory testing to voluntary counseling and testing (VCT) makes prevalence figures difficult to interpret as scepticism persists about the possibility of discrimination and legal consequences of a positive test result. The estimated number of people now living with HIV/AIDS is thought to be around four times higher than the reported figures. Due to the high costs and budgetary constraints within the publicly funded health systems effective anti-retroviral therapy for people living with HIV/AIDS (PLWHA) is rare in the region. It is estimated that less than 1000 people receive highly active anti retroviral therapy (HAART).
The countries of the Eastern Europe and Central Asia region share remarkably common characteristics, which make similar developments in the future very likely. Some of these are:
There is little reliable data about the magnitude, location, and progress of the epidemic. Due to a change from non-anonymous and mandatory mass testing to VCT, data is inconsistent.
Homosexual transmission is unclear as homosexuality is forbidden in most of these countries so that voluntary outing is rare.
Low level of awareness among decision makers and the general public about the disease and its potential impact upon economies and societies.
Severe stigma and discrimination attached to persons living with HIV/AIDS, combined with a perception that HIV only hits ”undesirable” populations.
Massive, costly and perhaps unreliable public testing for HIV.
A near total lack of infrastructure and capacity to provide any HIV/AIDS-related services, whether through prevention programs, VCT or treatment, care and services for PLWHAs.
The lack of computerisation limits the possibility to get a complete picture to support programs.
Heterosexual transmission is so far rare.
There is a rapid trend towards the spread of HIV/AIDS infection in Injection Drug Users (IDU) and a parallel fast increase of Sexually Transmitted Infections (STIs) which increases the risk of an imminent spread of HIV/AIDS into the heterosexual transmission group.
Few and weak civil society organisations.
Unemployment, poverty and increased injection drug use (IDU) in Central Asia contribute to the spread of HIV/AIDS. All five Central Asian countries serve as drug trafficking routes from Afghanistan to Russia and Western Europe. Local drug consumption patterns are influenced by ready access to drugs. People are switching from alcohol to heroin, which is cheaper, and heroin users are starting to switch from smoking or snorting to injection, because it is a more efficient method of drug ingestion. With easy access to and strong demand for illegal drugs, consumption has increased dramatically, particularly in the Black Sea area, which remains a regional gateway for drugs.
The deterioration of social networks and the economic pressure forces many women into sex work as their only source of income. A growing number of female IDUs are engaging in commercial sex work to fund their addiction. Young people are particularly vulnerable to HIV infection; the majority of drug users and sex workers in the region are under age 30. Official approaches to sex work and HIV prevention among sex workers have so far been either negligent or repressive. Although commercial sex workers are generally well informed about the protective effects of condom use, they are often not in a position to negotiate safer sex practices with their clients. Imported and Russian-made condoms are sold at some kiosks in Belarus, Kazakhstan, Russia, and Ukraine and are often of low quality or not affordable.
Information about HIV/AIDS patterns in men who have sex with men (MSM) groups is generally weak, as MSM who are found to be HIV positive would be strongly inclined to hide their sexual preferences due to social stigmatisation and partner tracing policies in most of the countries in Eastern Europe and Central Asia. Recent evidence from Russian surveys shows that most MSM are bi-sexual and more than one third had female partners in the last three months. The knowledge about critical HIV risk-reduction steps are low and consistent condom use is reported by less than a third of the interviewees. Around 20% of MSM engaged in sex for economic gain with mail and female partners.
While injecting drug use is currently responsible for three-quarters of HIV infections in Ukraine, more and more people (mostly women) appear to be contracting HIV through unsafe sexual behaviour and more pregnant women are testing positive for HIV. Meanwhile, very high rates of sexually transmitted infections continue to be found in Eastern Europe and Central Asia, increasing the odds of HIV being transmitted through unprotected sex.
Historically, there is a cultural reluctance to confront AIDS. In many countries of the region, groups engaging in high risk behaviour are discriminated or even criminalised and the status of PLWHA may not be any better. The still low prevalence of HIV/AIDS in many countries of Eastern Europe and Central Asia and the limited governmental budgets for health and development create the environment for a low level of political awareness of the pandemic. However, recently Government officials asserted that their countries are working to improve national policy frameworks, placing increasing emphasis on promoting coordinated responses to the HIV/AIDS threat.
Predictions on development trends of the HIV/AIDS epidemic in Central Asia and Eastern Europe depend largely on the spread of the infection from the current risk groups, mainly injecting drug users, to the general population. The window of opportunity to prevent a wide-scale epidemic is rapidly closing. A combination of critical factors fuel the rising HIV rates and provides a perfect breading ground for the spread of the HIV/AIDS pandemic in the region. Countries such as Ukraine and Russia are already beginning to exhibit changes in the dynamics of HIV infection. Without immediate intervention, the potential for a transition from a concentrated to a slower, more generalized form of the epidemic is imminent.
However, the epidemic is still at an early stage in the region and massive prevention efforts could curtail its scale and extent. Such efforts would require a comprehensive response to reduce risky sexual and drug-injecting behaviour among young people, and tackle the socioeconomic and other factors that promote the spread of the virus. An increasing number and variety of projects started from the mid 90s to work on sexual education, risk reduction in high risk groups and condom promotion.
*Manfred Zahorka is a family practitioner, public health expert and epidemiologist by training. He has been working for more than 15 years in public health and health systems development in developing and transitional countries in Eastern Europe, Central Asia and Africa. Currently, he is working with the Swiss Centre of International Health within the Swiss Tropical Institute in Basel. Contact: Manfred.Zahorka@unibas.ch
1. Incidence: Number of annual new cases in a previously disease free population
2. Prevalence: total number of cases at a given point in time
Resources used and Selected Links
USAID HIV/AIDS site for Eastern Europe and Central Asia, www.usaid.gov/pop_health/aids/Countries/eande/index.html
WHO page for the Department of HIV/AIDS, www.who.int/HIV_AIDS/first.html
The world bank HIV/AIDS site www.worldbank.org/aids
The Determinants of the HIV/AIDS Epidemics in Eastern Europe, MAP report 1998, www.hsph.harvard.edu/fxbcenter/MAPreports.htm
UNAIDS HIV/AIDS update for Eastern Europe and Central Asia, www.thebody.com/unaids/update1201/eastern_europe.html
HIV/AIDS and education: a strategic approach - Interagency draft by the World Bank, UNICEF, UNFPA, UNDP, WHO, UNESCO and UNAIDS www.unaids.org/index.html
The 2001 report ” HIV/AIDS Surveillance in Europe” www.eurohiv.org
Manfred Zahorka, Claudia Kessler Bodiang, HIV/AIDS/STI in Eastern Europe and Central Asia, A commissioned product established in the context of the mandate No. 7F-03874.14 of the Swiss Agency for Development and Co-operation (SDC), September 2002, Bern, Switzerland
Amirkhanian YA, Kelly JA, Kukharsky AA, et al.: Predictors of HIV risk behavior among Russian men who have sex with men: an emerging epidemic, AIDS 2001 Feb 16;15(3):407-12