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HIV and AIDS in Russia, Eastern Europe and Central Asia

The region discussed in this page includes 17 countries, stretching from Estonia down to Bulgaria, across to Russia, and south as far as Tajikistan, Turkmenistan and Armenia.

This is a large region and Russia alone is roughly twice the size of the USA. Although the region is large the population is less so; the population of Russia is less than half that of the US.

This region was home to around 1.6 million people living with HIV at the end of 2007.

Countries

Russia

Russia has the largest HIV epidemic in Europe, and accounts for around two-thirds of the cases in the Eastern Europe and Central Asia region. There were an estimated 940,000 people living with HIV at the end of 2005 in Russia - up from 760,000 in 2003 - and this figure looks set to increase even further.¹

The number of new HIV diagnoses being reported is falling however, with 88,577 new cases reported in 2001, 52,349 in 2002 and 39,699 in 2003. This reduction could be due to fewer people being tested, or it could be that HIV prevalence rates have reached saturation point amongst injecting drug users.

There are 12 regions in Russia, including the major cities of Saint Petersburg and Moscow, where HIV prevalence rates are said to be ‘above high’, and a further 11 with high prevalence rates.²

Ukraine

In Ukraine ten years ago there were 183 registered cases of HIV; by mid-2004 there were more than 68,000. UNAIDS estimates that in addition there were probably many more unregistered cases over that period. Tuberculosis is the leading cause of death among people living with HIV in Ukraine.³

As in Russia there are many injecting drug users (IDUs) in Ukraine. A 2002 survey of 212 IDUs in the region found needle re-use was widespread and condom use was low. However the same study found that many of those IDUs who knew they were HIV positive were found to be abstaining from sex or using condoms.⁴

Central Asia

Central Asia contains Kazakhstan, Uzbekistan, Turkmenistan, Kyrgyzstan and Kazakhstan. Throughout this area HIV epidemics are growing fast. In 1995 there were almost no reported cases in the region.⁵ However, from 2003 to 2005 the UNAIDS estimate of the number of people living with HIV infection more than doubled from around 24,000 to around 57,000.⁶

This region contains major drug trafficking routes between Russia and Europe, resulting in large amounts of injecting drug use. Indeed, in some parts of the region heroin is now said to be cheaper than alcohol.⁷

The Baltic States

The Baltic States consist of those countries in the north of Eastern Europe: Estonia, Latvia and Lithuania. Although overall numbers of infections remain low, HIV is spreading at an alarming rate in the Baltic States. Between 2000 and 2001 there was a large increase in the number of new reported HIV cases, from 921 to 2,353, the majority of which were reported in Estonia. Between 2001 and 2003 however the number of cases reported dropped considerably with Estonia and Latvia virtually halving their cases over the two-year period.⁸ This could be due to fewer infections, or to changes in reporting methods.

The Caucasus

The three countries between the Black and Caspian Seas - Georgia, Armenia and Azerbaijan - have much lower HIV prevalence rates than Russia. However the estimated number of people living with the virus in Azerbaijan grew from 1,400 in 2003 to 5,400 in 2005, and there is a high potential for explosive epidemic growth in all three countries. Some cities already have very high rates of HIV infection among injecting drug users.⁹

The impact of AIDS on countries

Countries such as Russia and Ukraine have a population that is getting older with declining birth rates. As HIV is mainly affecting the young in these parts the number of young people will be further reduced; this may result in many pensioners with few wage earners and a shrinking population as the elderly naturally die. It is estimated in Russia that GDP, investment and labour supply will all decline between now and 2020 unless there is an increase in effective HIV prevention.¹⁰ The deputy prime minister of Russia, Alexander Zhukov, has stated that ‘the growth of AIDS has gone beyond a medical problem, and has become an issue of strategic, social and economic security of the country’.¹¹

At the other end of the scale, in Central Asian countries, there is a high birth rate. An increase in AIDS related deaths here could result in many children being orphaned.

Children

The Romanian communist government in the 1980s believed that blood transfusions helped people to keep healthy and administered them unnecessarily to children in orphanages. Although these transfusions were thought to boost the immune system, ironically some of them were contaminated with HIV. In addition many of the nurses reused vaccination needles, further aiding the spread of the virus.

Today, whilst Romania has relatively low rates of HIV, it still has the highest rate of HIV/AIDS among children in Europe. There were reported to be 6,500 people living with HIV in Romania at the end of 2003 and the majority of these were said to be children.¹²

The AIDS orphans are often stigmatized. Families are not always happy about AIDS orphans being integrated into the community and do not want them playing with their own children.¹³ Fortunately, almost all children are receiving treatment and Romania now holds the world’s largest paediatric AIDS clinic treating 600 patients with antiretroviral drugs.¹⁴

Discrimination against children affected by HIV is widespread elsewhere in the region as well. Each day on average two babies born to HIV-postive women in Russia are abandoned by their mothers. Although orphanages are legally obliged to accept these infants, fear and prejudice result in many of them being isolated in hospital wards for months or even years.¹⁵

Drugs, sex and HIV

There are a number of issues occurring today in this region which contribute to the spread of HIV.

Drug use

A large number of people throughout this region use drugs, especially injecting drugs. For example, in Russia roughly 2% of the population - 2 million people - are IDUs.¹⁶ Since unauthorised possession of needles and syringes is illegal in much of this region, many drug users are compelled to share needles. In addition, reports suggest that it is sometimes actually considered rude in Russia not to share needles when taking drugs.¹⁷ An estimated 30-40% of injecting drug users in Russia use non-sterile needles or syringes.¹⁸

Non-sterile needles combined with poor health care, fear amongst drug users of using available health care, and sharing of needles, have all led to the spread of HIV amongst this group. In the capital of Azerbaijan, Baku, one in four street drug users was found to be HIV positive.¹⁹ Many of those using drugs are young, and consequently HIV affects many young people in this region, with more than 80% of those infected aged under 30.²⁰

Sex workers

There are many sex workers operating throughout this region. A large number of these are working in exchange for drugs or in order to get money for drugs. One study in Moscow found that many sex workers also injected drugs using non-sterile injecting equipment and of this group 45% were HIV positive.²¹

Sex workers are also engaging in sexual relations on a regular basis and may or may not use protection. Even if they do use condoms with clients, they may not with their regular partners, and this factor, combined with the potential for contracting HIV from sharing needles, makes them a high risk group who can easily contribute to the spread of HIV.

Prison conditions

Prisons in this area are often very overcrowded and unsanitary, with some Romanian prisons having up to a 700% occupation rate.²² Many of those imprisoned are IDUs, put in prison simply because they use illegal drugs. Of these people a majority continue to use drugs in prison and to share needles, and there is also unprotected sex between men. This leads to the spread of HIV amongst the prisoners.

The spread of HIV

The diagram below shows some of the main ways the groups described interact, increasing the spread of HIV. It shows the following scenarios:

• Prisoners contracting HIV in prison can infect partners, drug users they share needles with, and sex workers with whom they have unprotected sex.
• Sex workers are vulnerable to HIV from having unprotected sex with clients, partners and from sharing needles.
• Partners of people who have become infected with HIV from sharing needles or unprotected sex with sex workers can go on to infect other partners, who may fall into none of the assumed “high risk” categories.

In actual fact the situation is much more complex than this; there are many more scenarios, and many people fall into more than one group. This existing combination of a thriving sex trade, high levels of drug use and unprotected sex means it may be easy for HIV to continue to spread in certain regions throughout Eastern Europe and Central Asia unless appropriate prevention methods are in place and being acted on.

Women

Sexual transmission of HIV is increasing in the most affected areas of Russia. Heterosexual infection has grown from 5.3% of all infections in 2001 to 20% in 2003. In Ukraine 40% of those infected with HIV are women. When more women are infected, more babies are born with HIV as well.

In 1998, 125 cases of pregnant women in Russia with HIV were reported, whereas in 2003 there were 3,531 cases. In total there have been 9,000 reported cases of babies being born with HIV in Russia up to and including 2003. In Ukraine however there are many programmes in place to prevent mother-to-child transmission and the percentage of babies born with HIV fell from 27% in 2001 to 12% in 2003.²³

Prevention and education

European countries pledged to ensure universal access to treatment and care by 2005 across the whole of Europe and Central Asia and aimed to make sure 80% of ‘high-risk’ people have access to prevention services by 2010. At the end of 2004 however, only a small percentage of ‘high-risk’ people were being reached by prevention programmes²⁴ and in Russia in April 2005, Cesar Chelala, an international public health consultant, stated that prevention efforts were almost nonexistent. On a positive note, in Central Asia a prevention project has been launched which will train medical workers and other people, and it is thought this and other treatment and prevention programmes could make a real difference in the area.²⁵

In 2004 a survey was conducted in Moscow which found that 70% of people interviewed felt ‘fear, anger or disgust towards those living with the virus’.²⁶ Similarly, a survey in Samara Oblast found that ignorance and discrimination were widespread, even among health workers and family members. Many people were afraid that they could acquire HIV through casual contact; some suggested isolating all infected people from the rest of the population.²⁷

In order to help change these types of negative attitudes a poster campaign was launched by UNAIDS and a Russian community group in 2004 featuring famous paintings alongside slogans such as ‘HIV is NOT transmitted through sport’.²⁸ Ukraine launched its own public information campaign in September 2005 with a World Bank backed television advert being shown daily for three months highlighting the fact that 8 Ukrainians die of AIDS every day.²⁹

Harm reduction

Harm reduction programmes seek to help protect drug users from drug-related harm such as becoming infected with HIV. Whilst these programmes do not deny the benefits of giving up the drugs altogether, they recognise that total abstinence is very difficult for addicts, and in some cases impossible.

One aspect of a harm reduction programme is the introduction of needle exchanges where injecting drug users can exchange dirty needles for clean ones. If a clean supply of needles is available to injecting drug users then they will be less likely to share needles, therefore reducing the risk of contracting HIV. For example, in a major study of 81 cities around the world on HIV infection rates amongst IDUs, it was found that in 52 cities without needle exchanges HIV infection increased year on year, whilst in those cities with needle exchanges HIV infections decreased year on year.³⁰

In addition to needle exchanges, harm reduction programmes also look at ways of encouraging IDUs to stop using drugs. One key way of doing this is by providing them with alternatives such as methadone. These alternatives are administered at clinics, and once inside, visitors can be offered further tests and treatment. Psychological assistance can be provided also, making the visitor feel valued and enriching their life.

Unfortunately, harm reduction services in Russia, Eastern Europe and Central Asia are not nearly adequate to meet demand. In general authorities prefer to criminalise drug users rather than help them to give up drugs or avoid infection. In some countries - including Russia - substitution treatment with methadone is illegal.³¹

Where they do exist, some harm reduction clinics have met with resistance from potential users due to wariness of government agencies. There are a number of ways the clinics deal with this, one example being that of Darko Kostovski, a Macedonian physician who has taken to wearing a Star Trek uniform to put the visitors at ease.³²

Treatment

At the end of 2006 only 15% of those requiring antiretroviral treatment for HIV infection in this region were receiving it. Only Moldova and Romania are providing treatment to most of those in need. Although Russian law guarantees people treatment, only around 16,000 (11%) of the 140,000 needing treatment were receiving it at the end of 2006. Coverage is much lower than in many poor African countries such as Zambia (35%), Malawi (43%) and Uganda (41%), which have much more severe epidemics.³³

One reason for the low treatment figures is that medicines are very expensive. This is however becoming less of a problem, particularly in Russia.

In early 2005 the Russian minister of health, Mikhail Zurabov, announced that agreements had been made with pharmaceutical companies which would reduce the amount an AIDS patient had to spend on medicines from US$10,000 a year to around US$3,000.³⁴ The Russian government then announced in late 2005 that it would make AIDS a priority and pledged to spend at least 20 times more on treatment and prevention in 2006 than it spent in 2005.³⁵ A year later it was announced that spending would be doubled to US$289 million in 2007.³⁶ This increase has been aided by the Global Fund to Fight AIDS, TB and Malaria, which has pledged US$209 million over five years for treatment programmes.³⁷

Yet although it is hoped that the extra money will enable a rapid expansion of treatment access in Russia, there are other issues to address besides funding, including pervasive discrimination and segregation. People living with HIV in Russia must attend special clinics for all of their medical needs. These clinics are isolated from the rest of the health care system and anyone who visits them risks being stigmatised. Moreover, the lack of integration means that doctors and nurses in non-specialist clinics have very little knowledge of HIV.³⁸

Even specialist doctors are often unwilling to treat injecting drug users because they doubt they will be able to adhere to the medication.^{39 40}

Conclusion

In Russia and Ukraine the number of people with HIV looks set to increase, but there is still time to reverse this trend with the introduction of harm reduction programmes, other prevention programmes and improved testing and treatment. The countries in Central Asia are still in the early stages of the spread of the disease and, by following the example of countries such as Romania that have achieved treatment for all and minimal spread, could stop the disease from reaching the levels it has in Russia.

For further information, see our web page on HIV and drug use. For more Eastern European HIV & AIDS statistics, see our European summary.

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