Dr. Irina McKeehan Campbell, NY Academy of Medicine, International Society of Urban Health, Global Security & Transmission of HIV among Urban Adolescents in Ukraine

3rd Annual Conference International Society for Urban

Health New York Academy of Medicine

October, 2003Irina V. McKeehan Campbell, Ph.D., M.P.H., Columbia University, NYC, USA --- [email protected]

Serge Pozdnyakov, M.D., Ph.D., Department of Health, Odessa, Ukraine with

T.Gerasimenko, L. Mogilevsky, Y.Boschenko, V.Filyuk, L.Averbukh, I.Gridasova, T.Moskalenko, V.Odinets,

A.Sherbinskaya, Y.P.Dobrov

Global security and the transmission of HIV among

urban adolescents in Ukrainian and Russian Cities:

Odessa, Nikolaev, Kherson, Donetsk, Simferopol, Kharkov, Poltava

DEFINING THE UKRAINIAN SOCIOECONOMIC PROBLEM

selected economic indicators 1994 1995 1996 1997 forecast

Nominal GDP UAH million 12038 54516 80510 90100Real GDP per cent change on previous year -23 -12.2 -10 -2.9Consolidated budget revenue per cent of GDP 43.5 38 37.5 30.4Consolidated budget expenditure per cent of GDP 52.4 44.6 42.5 36.2Consumer price index per cent Dec-Dec 501 282 140 110

Source: International Centre for Policy Studies, Quarterly Predictions, September 1997, Kyiv, 1997

♦Ukraine: 1987 - first HIV case ♦1995 - 3 epidemics of HIV/AIDS, tuberculosis (TB), drug abuse (DA) ♦2003 - 52,000 HIV+ officially registered >4,000 patients with AIDS♦Black Sea Region: 2003 - 12,311 HIV + officially registered among which

are 2,074 patients with AIDS♦3 stages of epidemic connected to HIV transmission routes

SOCIAL RISKS TO GLOBAL SECURITY AND HEALTH

♦ Changing inter-ethnic balance

♦ Insufficient flows to deal with lack of skilled labor force and population replacement

♦ Public social safety net strained across borders between Russia, Ukraine, Central Asian Republics, China, Far East

♦ Unstable FSU economics, politics, religious strife

♦ Flow from FSU to EU, USA, dev. nations

♦ Flow from Siberia, Far East to European Russia

♦ illegal migration > 500,000 Chinese to Russian Far East

♦ >700,000 fleeing environmental disasters

SOCIAL RISKS: MIGRATION

♦ Illegal migrants smuggled in a $10-$12 billion/yr industry

♦ Global smuggling involves corrupt governments (ILO)

♦ Prices for single border trips ~ $500; ~> $70,000 for multiple border trips from Asia to Europe and USA

♦ Trafficking in women and children for labor and sexual exploitation ~ 700,000 in 1997, (~50,000 to US)

♦ Compromised national security of borders and distribution of public goods

ROUTES: ILLEGAL MIGRATION & TRAFFICKING

IN WOMEN/ CHILDREN

STAGES OF GLOBAL HIV EPIDEMIC

STAGE 1 - UNKNOWNSTAGE 2 - NASCENTSTAGE 3 - CONCENTRATEDSTAGE 4 - GENERALIZEDSTAGE 5 - GENERATIONAL

–mother-child transmission– adolescents

WORLD BANK DEFINITIONS OF GLOBAL HIV STAGING

♦ NASCENT =HIV EPIDEMIC IN COUNTRY WHEN <5% OF INDIVIDUALS BELONGING TO HIGH-RISK GROUPS ARE INFECTED WITH HIV

♦ CONCENTRATED =HIV EPIDEMIC IN COUNTRY WHEN >=5% OF INDIVIDUALS BELONGING TO HIGH-RISK GROUPS ARE HIV+ BUT <5% OF WOMEN ATTENDING URBAN ANTENATAL CLINICS ARE INFECTED

♦ GENERALIZED = HIV EPIDEMIC IN COUNTRY WHEN >=5% OF INDIVIDUALS BELONGING TO HIGH-RISK GROUPS ARE HIV+ AND >5% OF WOMEN ATTENDING URBAN ANTENATAL CLINICS ARE HIV+

♦ HIGH RISK BEHAVIORS DEFINED BY WORLD BANK STAGING TEAM AS:

1.) UNPROTECTED SEX (WITHOUT CONDOM)

2.) MANY PARTNERS3.) SHARING NEEDLES

(UNSTERILIZED)

STAGING OF HIV

SENTINEL SURVEILLANCE SURVEYS, UKRAINE, 2002: % HIV+ by Cities and Risk Groups

Source: Introduction of New HIV Surveillance Methods in the Ukraine. Kiev, 2003:52.

City Sex-workers (F)

Sex-workers (F) -IVDU

STDs Patients

IVDU

Donetsk 31.4 35.6 1.2 40.0Lutsk 3.9 33.3 1.3 32.0Nikolaev 30.0 83.3 27.7 53.2Odessa 22.3 33.3 9.6 58.3Poltava 17.0 34.3 1.7 31.6Simferopol 6.0 31.6 12.3 28.0Kharkov 12.2 38.9 0.3 16.8

EPIDEMIC STAGE 1: Nascent 1987-1994

Dominant transmission - SexualOdessa oblast 94

3Nikolaev oblast ~1

~1Kherson oblast ~1

~1TOTAL 88

3

SEXUALIVDU

BLACK SEA REGION

EPIDEMIC STAGE 2: Concentrated 1995-1997Dominant transmission - IVDU

Odessa oblast 2670

Nikolaev oblast 490

Kherson oblast 1086

TOTAL 1272

SEXUALIVDU

BLACK SEA REGIONOdessa

Region

Nikolaev

Ukraine

Kherson

EPIDEMIC STAGE 3: Generalized 1998-2002

Dominant transmission: >Sex+IVDU

Odessa oblast 3460

Nikolaev oblast 887

Kherson oblast 1576

TOTAL 2563

SEXUALIVDU

BLACK SEA REGIONOdessa

Nikolaev

Black Sea Region

Ukraine

Kherson

EPIDEMIC STAGE 4: Generational >2002

Dominant transmission: Adolescents & Children

Student groups (N=1520)University 1

University 2

University 3

College

High school

Drug Users 10028

73

10

10

Comparisons between subjective and objective methods of evaluating the extent of engaging in behaviors which increase exposure to HIV/AIDS, by students, aged 15-22,

Positive Evaluation for Risk Group Membership

objective evaluation = listing at least 1 out of 3 risk factors: transmission routes; prevention modes; lifestyle practices;

subjective evaluation = "yes, I feel that I am engaging in behaviors which put me at risk for getting HIV/AIDS " ;

62

3916

1054

53

26

END STAGE: MORTALITY1996-2001, Ukraine (per 100,000)

Odessa

Region

Nikolaev

Ukraine

Kherson

HIV TRANSMISSION IN IV DRUG USERS, 7 CITIES, UKRAINE, 2002♦ 45% - obtain drug into own syringe from syringe of dealer.♦ 12% - obtain drug within a syringe.♦ 33% - are not sure if drug is infected or not.♦ 14% - in last injection used syringe of other users.♦ 32% - in past month, used syringe of other users.♦ 19% - used syringes obtained from one or two others.♦ 7% - used syringes obtained from three or more others.♦ 25% - in past month, gave own syringe to other IVDUs.♦ Syringes are legally available in pharmacies

-92% know that they can buy syringes, but do not.

SEXUAL PRACTICES IN SEX WORKERS, 7 CITIES, UKRAINE, 2002

% sex-workers using condoms:♦ 55% - always use condoms in contacts with clients♦ 25% - use condoms in more than half of contacts♦ 9% - use condoms in less than half of contacts♦ 7% - never use condoms in contacts with clients

% sex-workers confirming sexual relations with:♦ 27% - bisexuals♦ 37% - Drug Users (IVDU)♦ 7% - possible STDs patients♦ 3% - possible HIV-positive

Subjective and objective methods of evaluating knowledge about HIV/AIDS

Student groups (N=1520)University 1

University 2

University 3

College

High school 3

Drug Users

64

60

31

80

Evaluation of having sufficient level of knowledge

71

Subjective and objective methods of evaluating having knowledge about HIV/AIDS, students,

aged 15-22, Odessa, 2002

15

47

17

80

59

33

SUMMARY ♦ USA HIV solutions need a global perspective

♦ HIV Migration back to the USA ♦ Europe and Central Asia

♦ Ukrainian centrality♦ Geopolitically

♦ Regionally♦ Socially

♦ Expanding Global Threat of HIV/AIDS♦ Intergenerational investment in HIV & disease

prevention & health promotion

CONCLUSIONS♦Use WHO Sentinel Surveillance Survey

methodology to evaluate global HIV/AIDS

♦ Implement continuously evolving education programs in each newly arriving Generation

♦Update Ukrainian and NGO HIV/AIDS programs - Education

- Prevention- Treatment- Research