February 9, 2004
It may come as a surprise that the fastest-growing HIV epidemic is occurring not in Africa or China, but in the states of the Former Soviet Union (FSU), and new evidence suggests that it may now be spreading from intravenous drug users into the general population, according to studies presented at the 11th Conference on Retroviruses and Opportunistic Infections (CROI 2004).
Some of the first cases of HIV in the area were in the early to mid- 1990s among FSU navy servicemen at port cities in Russia and the Ukraine. Since then, the numbers have skyrocketed as HIV has spread rapidly through a network of intravenous drug users (IDUs). Along with HIV, the use of intravenous drugs has increased dramatically since the region's economic collapse. Today, HIV/AIDS population prevalence rates are estimated to reach as high as one to 1.5 per thousand in Estonia, the Russian Federation, Ukraine, and Latvia. In the Russian Federation, some estimate that as much as two percent of the population is infected with HIV.
The two epidemiological studies of the region presented at CROI confirm both the harsh reality of HIV?s swift spread, and its recent move outward into the non-IDU population. Both studies found an increase in the number of women getting HIV, presumably from sex with IDU partners. Neither of the studies included any surveillance of transmission among men who have sex with men.
In one study, ?Expanding Epidemics of HIV-1 in States of the Former Soviet Union,? Colonel J. L. Sanchez and a team of U.S. military researchers examined past epidemiological studies of the region and U.S. military documents concerning the spread of HIV to U.S. military personnel. To clarify exactly which populations were infected, they also conducted a genotyping study among HIV-positive patients in Kazakhstan, Uzbekistan, Azerbaijan, Georgia, and the Ukraine. They did this by sequencing the reverse transcriptase and protease gene regions of HIV-1 strains collected from 207 HIV-positive patients from 2000 to 2003. They found that subtype A predominated, and was similar to the subtype A strains found among IDU networks in the region. The genetic composition of the HIV they found in the population studied was unique, and was mostly restricted to IDU networks in the region. However, they also found evidence that this exact strain of the virus is now rapidly spreading to the non-IDU population, including commercial sex workers and female partners of male IDUs. Through tracing this strain, they concluded that IDUs are the main bridge in transmission to the general population.
The other CROI presentation on the subject confirms what Colonel Sanchez found, but on a smaller scale. Dr. Dmitri Lioznov, from the Pavlov State Medical University in St. Petersburg, examined previously published epidemiological data and study results concerning the incidence and prevalence of HIV among different gender, age and risk groups in St. Petersburg.
Dr. Lioznov found that HIV incidence in St. Petersburg increased dramatically over the last four years, from 2.3 per 100,000 people in 1998 to 215.6 per 100,000 in 2001. Researchers also discovered an increase in reported cases of HIV among pregnant women; there were 469 more cases reported in 2002 than in 2001. The primary route of HIV transmission there is intravenous drug use, Dr. Lioznov says, with more than 80 percent of HIV-infected people reporting a history of IDU. As was expected, the researchers also found that 79-93 percent of HIV-infected people are also co-infected with HCV.
Why has this region, which stayed relatively HIV-free while countries like the U.S. were mid-battle, suddenly erupted in epidemic? One major reason has been the 400% increase in intravenous drug use from 1992 to 2000, according to Colonel Sanchez. He also sites a growing social acceptance of sexual promiscuity, a higher number of men and women turning to commercial sex work for income since the collapse of the Soviet economy, and the fact that 4% of the incarcerated population in FSU states is HIV positive. Upon release, these former inmates facilitate the spread of the disease to the general population.
Further, the lack of effective prevention and treatment programs could push the region into an economic tailspin, as its pool of young and able workers continue to fall victim to the disease. More than 80 percent of new HIV cases in the region occur in people under 30 years old, says Colonel Sanchez, and, by his numbers, HIV will cause the Gross Domestic Product of the area to decrease by 4%.
It?s no wonder that the U.S. military is worried about the area; with the economy depressed and disease ravaging the country?s youth, the FSU is a potentially volatile part of the world. But why are people like Colonel Sanchez so concerned that the epidemic will affect U.S. military personnel? A study of the impact of HIV on the military found that military personnel are at a greater risk of HIV infection than the general population because they are mainly young and sexually active.1 Long periods of deployment in high-endemic countries, sexual activity with commercial sex-workers, and the risk-taking culture of the work environment also contribute to the risk of infection. The military therefore has enormous interest in HIV research in high-endemic areas such as the FSU, and say that they are looking for ways to complement local prevention efforts while stationed in the area.
Colonel Sanchez believes there is a potential for millions more people in the region to be infected with HIV once the virus gains a foothold in the sexually active non-IDU community, and his data suggest this may already be underway. However, if interventions can be developed and implemented immediately, there is a chance that the epidemic can be slowed or stopped it before it spirals out of control. Unfortunately, that doesn?t seem very likely.
Abstract: Expanding Epidemics of HIV-1 in States of the Former Soviet Union (Poster 867)
Authored by: J. Sanchez, J. Carr, R. Graham, W. Sateren, E. Latta
Affiliations: US Military HIV Res. Prgm., Walter Reed Army Inst. of Res., Rockville, MD, USA; Henry M. Jackson Fndn. for the Advancement of Military Med., Rockville, MD, USA; US Naval Med. Res. Unit No. 3 (NAMRU-3), Cairo, Egypt; Armed Forces Med. Intelligence Ctr., Defense Intelligence Agency, Fort Detrick, MD, USA
Abstract: HIV Disease Burden in St. Petersburg, Russia (Poster 868)
Authored by: D. Lioznov, M. Tsoy, V. Egorova, S. Nikolaenko, A. Diachkov, O. Nikitina, E. Krupitsky, E. Zvartau, .T Antonova, T. Belayeva
Affiliations: Pavlov State Med. Univ., St. Petersburg, Russia