HIV/AIDS in Eastern Europe Setting the Stage for Prevention

HIV/AIDS in Eastern EuropeSetting the Stage for

Prevention

HIV/AIDS in Eastern EuropeSetting the Stage for

Prevention

Thomas E. Novotny, MD, MPH

April 16, 2004

HIV/AIDS in Eastern EuropeBackground

• Most rapid rate of increase in new HIV infections among all regions of the world;

• Transition and economic disruption may lead to increased risk behavior (IDU, trafficking) and reduced prevention and treatment services;

• Prevention opportunities based on lessons learned in the region and from outside.

Adult prevalence rate 15.0% – 36.0% 5.0a% – 15.0% 1.0% – 5.0% 0.5% – 1.0% 0.1% – 0.5% 0.0% – 0.1% not available

+ 1 300%

+60%

+ 160% + 100%

+ 30%

+ 40%

+ 20% +20%

+ 20%

Global HIV: Change in Prevalence Rates 1996–2001

0

50

100

150

200

250

300

350

1993 1994 1995 1996 1997 1998 1999 2000 2001

Year of report

C ases per million

East

Centre

West *

HIV infections newly diagnosed per millionpopulation, by year of report (1993-2001) and

geographic area, WHO European Region

* Austria, France, Italy, Netherlands, Portugal, Spain excluded: national data not available for the whole period

EuroHIV

Upd

ate

at 3

1 D

ecem

ber

200

1

East: recent, concentrated* epidemic

Major HIV epidemic among IDUl expanding rapidly to all countries

Danger of large scale sexual transmission of HIVl increasing numbers of reported heterosexual infections

l low numbers of reported homosexual infections may reflect highvulnerability rather than absence of HIV epidemic in homo/bisexual men

l high prevalence of other STIs

Safety of blood supply needs urgent attention

Inevitable severe AIDS epidemic in near futurel resulting from current HIV epidemic

* HIV prevalence consistently >5% in at least one defined sub-population and <1% in pregnant womenEuroHIV

Upd

ate

at 3

1 D

ecem

ber

200

1

Causing or Aggravating Poverty

•Loss of income

•Catastrophic cost of care

•Increased dependency ratio

•Loss of productivity

(companies)

•Loss of social capital

(countries)

•Reduced national income?

CONTRIBUTORS TO POVERTY

HIV

Infection

AIDS

Impacts for Generalized Epidemic of HIV/AIDS

• 0.5-1.0 percentage point decline in economic growth

• 50-100% increase in health expenditures– Impact private sector development– Aggravate informalization of economy

• Change in dependency ratio, straining social systems

• Change in HH size and composition (single parents, orphans, elderly caring for children

• Negative intergenerational effects: Poverty trap

Transmission Groups and Risk

• Main mode is heterosexual: IDU (80%)• Little MTCT• Romania: Nosocomial and now heterosexual

(n=8,000)• MSM underreported• Structural factors in ECA: social disruption, open

borders, economic crisis• Mobility and globalization• Increases in STIs• Youth most at risk (age 20-30 years)

Mobile PopulationsExample: SE Europe

• Merchant marines, truckers (37% have unsafe sex while traveling)

• Peacekeepers

• Roma and other ethnic minorities (8 mil.)

• Trafficked women (and children)

• Commercial Sex Workers (CSW)

• Tourists

Effective Interventions

• CSW: 100% condom use, STI treatment, client education, peer education and outreach

• IDU: demand reduction, condom social marketing, needle exchange and cleaning education, treatment

• Youth: school reproductive health education and peer support

• Contacts: tracing, voluntary testing and counseling, referral

• STI surveillance, syndromic treatment

Harm Reduction

• Needle exchange

• CSW outreach, reproductive health services

• Drug abuse treatment (Methadone)

• Condom distribution

• Decriminalization of drugs and prostitution

Challenges in Low Prevalence Countries of ECA

• Lack of recognition of future potential• High levels of stigmatization (HIV+, IDU, CSW, ethnic

minorities)• Lack of government ownership of harm reduction (HR)

approaches• Lack of sentinel surveillance among most vulnerable

populations• Most funds go to treatment and not prevention

programs• Lack of evaluation on HR and other prevention

interventions• Increase in sexual risk behavior

Conclusions: HIV/AIDSin Low Prevalence Countries

• Opportunity for prevention is now• Cross-border externalities important in

addressing most vulnerable groups• Future burden on health systems and economic

productivity may be enormous• Need sentinel surveillance in high risk groups

and vulnerable populations• Harm reduction, harm reduction, harm reduction• Public information and professional education

are essential

IGH/CAPS Activities

• ICOHRTA Supplement with Croatia (NIDA)• Regional training in the Balkans• Eastern Europe/Central Asia Working

Group• Research and writing for World Bank

publications (Central Asia, Balkan, ECA)• Modeling epidemic and economic impact

in the Baltics