Fears of an Eastern European explosion of HIV epidemic are being realized
Area has fastest-growing epidemic in world
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With a quarter of a million new infections in 2001, HIV incidence is rising faster in Eastern Europe than anywhere else in the world. The number of people living with HIV in Eastern Europe doubled last year to an estimated 800,000. The epidemic’s spread appears to be fostered by the region’s high unemployment, economic insecurity, liberal social and cultural norms, and disintegrating public health services, according to the 2001 AIDS epidemic update by UNAIDS and the World Health Organization (WHO) of Geneva, Switzerland. The epidemic is fueled primarily by injection drug use and is characterized by high infection rates among people under age 20 who are experimenting with drugs, says Peter Piot, UNAIDS executive director.
Ukraine has highest HIV prevalence in region
The region’s epidemic started in Ukraine in 1996. Now that country has an HIV prevalence rate of 1% (the highest in the region), and nearly 75% of Ukraine’s HIV-positive population has been infected through injection drug use. HIV has spread throughout all of Eastern Europe, most recently growing rapidly in Russia and the Baltic states, says Henning Mikkelsen, MA, senior advisor for UNAIDS.
Nearly a decade before the region’s epidemic began, thousands of Romanian children became infected with HIV through blood transfusions. "In Romania, we’re having problems, not only with prevention, but there’s a major effort on treatment because of the children who were infected," Piot says.
Unfortunately, there are still problems with the region’s blood supply because many of the countries pay blood donors and don’t have access to HIV blood tests, Mikkelsen says.
However, there are positive signs that Eastern European governments are beginning to take the epidemic seriously, Piot says. "The former Soviet Union now has had a meeting on AIDS on a political level," Piot says. "And in Central Europe there are several countries doing a good job with prevention, like in Poland, where prevalence rates are among the lowest in the whole world."
The HIV prevalence among adults in Poland in 1999 was 0.07%, and new HIV infections have been relatively stable there for many years, says Peter Ghys, manager of epidemics and impact monitoring at UNAIDS.
Still, too few resources have been directed to HIV prevention, testing, and treatment among Eastern European nations, Piot notes. "There is too much business as usual and no sense of urgency with which we believe AIDS should be treated here now," Piot says.
Although the epidemic has been spread primarily by injection drug use, it is not the same type of epidemic that might be found among injection drug users (IDUs) in Amsterdam or New York City, Mikkelsen says. "It’s not confined to a small and stable community of drug users, which is the usual way," Mikkelsen says. "It’s very different there because the scale of injection drug use is so large, with 1% of the people in Russia injecting drugs." In the Russian Federation there has been a 15-fold increase in HIV in the past two years, with the number of people infected climbing from an estimated 10,000 in 1999 to 170,000 in 2001, Mikkelsen says.
"One of the more dramatic experiences was in the small country of Estonia, which used to have four or five cases a year," Mikkelsen says. "In the previous 12 months there were 600 cases of HIV in a population of 1.4 million, and the real number is probably five times higher than that." Prevalence of IDUs among young people is very high, and many begin to inject drugs when they were 13 or 14 years old, he explains.
Also, these same young people are highly sexually active with many sexual partners, and they engage in high-risk sexual activity with both homosexual and heterosexual partners, Mikkelsen says. As a result, mother-to-child HIV transmission is on the rise in the region, and the epidemic is spreading faster than it has spread in sub-Saharan Africa and other regions. "This is primarily because of the link through injection drug use, and it is primarily infecting men, but we’re seeing more and more women getting infected," Mikkelsen says. "And the result will be more and more babies with HIV."
Heroin cheaper than vodka
Homemade heroin, which did not have a market in the region a decade ago, now is rumored to be cheaper to purchase than vodka in Eastern Europe. It’s coming mostly from poppy fields in Afghanistan, Mikkelsen adds. The easy availability of heroin coupled with the shortage of clean needles and a lack of public education about HIV and drug use, as well as limited access to treatment, have all contributed to the HIV explosion, Mikkelsen says.
Another contributing factor is the major change in social and political barriers that were in force during the Communist era, as well as economic collapse in many areas, which causes high unemployment among youths. "Like all young people, these young people are trying to find their lives, but they can’t look back at their parents any longer because the way their parents lived and worked has changed," Mikkelsen says. "There is high unemployment and a lot of uncertainty among young people."
In addition to a need for sexual education in schools, there is a need for community programs that teach young people life skills and help them find their identity apart from experimentation with sex and drugs, he explains. "The good news is that the epidemic has started to trigger action," Mikkelsen says. "People are alarmed both inside the region and outside." The Russian government is beginning to exhibit interest, and the entire region has the benefit of learning from the Western world’s experience. There also are many organizations devoted to helping regions where the epidemic is a major problem.
However, the ability to treat HIV-infected patients remains a problem in Eastern Europe, Mikkelsen says. "Opportunistic infections are a big problem in many of the countries," he explains. "They have a high level of medical expertise, but they are not used to dealing with opportunistic infections, so this is a problem." Also, there is a need for a system of comprehensive care and support for people living with AIDS, including psychosocial care, support, counseling, and human rights education. People living with AIDS are highly stigmatized in the region, both for the infection itself and for the perception that people with HIV have used drugs and are men who have sex with men, Mikkelsen says. "We’ve heard of examples of people being stoned from the villages they live in and barred from jobs," he adds. "The epidemic is invisible to most people because those with it mostly are not ill yet."
Since the epidemic began in 1996, and it takes eight to 10 years on average before people develop AIDS-related illnesses, the heaviest burden on health care systems is yet to come. "What people have difficulty in understanding is that HIV is a long-time challenge," Mikkelsen says. "It’s not like an earthquake or disaster where it happens and then goes away. It will take a decade before we see the real repercussions."