- Russia's HIV/AIDS Epidemic: Status And Outlook
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- Russia has recently emerged as a new epicenter in the
global HIV/AIDS pandemic, with one of the world's highest rates of new
infection. As of August 2003, there have been more than 245,000 officially
diagnosed cases of HIV infection in Russia, over 80 percent of which were
reported in the last three years. It is widely acknowledged, however, that
Russia's official statistics represent only a fraction of the actual number
of HIV-infected Russians; most experts estimate that the true number is
somewhere between 1.5 million and 2 million citizens, or over 2 percent
of the adult population.
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- Epidemiologists warn that up to 8 million Russians -
over 10 percent of the adult population - could be infected by 2010, under
worst-case scenarios. The epidemic is growing fastest among young people
aged 15-30, the very same group that should be leading Russia into the
21st century. Figure 1 shows the dramatic growth of Russia's HIV epidemic
between 1994 and mid-2003, as measured by official cases of HIV diagnosis
registered with the Russian Federal AIDS Center.
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- Recent reports that the rate of new HIV infection in
Russia is declining are almost certainly misleading. Since 2000, the number
of people in high-risk groups tested for HIV has declined dramatically.
According to official statistics compiled by the Russian Federal AIDS Center,
the number of injecting drug users tested for HIV infection dropped from
a high of 524,300 in 2001 to 331,100 in 2002; this may explain why there
were only 10,298 cases of HIV infection registered among drug users in
2002, when almost three times that figure were diagnosed in 2001. Moreover,
the federal government has recently stopped the supply of HIV test kits
to the regions; for those regions that cannot afford to purchase their
own test kits, the number of tests (and the number of officially diagnosed
HIV-positive people) has therefore declined.
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- Although HIV infection has been reported in virtually
all of Russia's 89 regions, there are a number of geographic "hot
spots" where HIV prevalence rates are much higher than average. Russia's
largest urban centers, Moscow and St. Petersburg, are epicenters for HIV/AIDS,
as are the strategically important cities of Kaliningrad, Togliatti, Norilsk,
and Khanty-Mansiysk. In Norilsk, over 1 percent of the adult male population
is already officially diagnosed with HIV.
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- At the end of 2002, 11 regions of the Russian Federation
reported HIV-prevalence rates above 300 cases per 100,000 citizens. Of
greatest concern are six regions that have prevalence rates higher than
500 cases per 100,000: Sverdlovsk oblast (which includes Yekaterinburg);
Leningrad oblast; St. Petersburg; Samara oblast; Irkutsk; and Orenburg
oblast. According to the Russian Federal AIDS Center, 39 percent of the
entire Russian population is now living in regions where between 0.2 percent
and 0.6 percent of the population is officially diagnosed with HIV.
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- High-Risk Groups and Bridge Populations
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- Over the past decade, HIV transmission in Russia has
been concentrated within a number of high-risk populations, among which
there is considerable overlap: (1) injecting drug users (IDUs); (2) sex
workers; and (3) prisoners. Men who have sex with men (MSM) and migrant
workers, especially those from Central Asia, are additional populations
with high concentrations of HIV. The future of Russia's HIV/AIDS epidemic
will turn on the degree to which these high risk groups serve as "bridge
populations" for transmitting the virus into the heterosexual, nondrug
using population. Notable indicators that this shift is already underway
include the rapid rise in curable sexually transmitted infections in the
general population and the growing rate of new HIV infections among women
over the last two years.
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- Injecting Drug Users
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- Since the early-1990s, drug use in Russia has exploded.
Russia's Ministry of Health estimates that drug use soared by 400 percent
between 1992 and 2002. According to numerous studies, drug users in Russia
represent a larger share of the total population when compared to other
countries.
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- There is a direct connection between injecting drug use
and HIV. Given the widespread use of shared needles and other equipment,
HIV has spread swiftly through Russia's drug subculture in the past five
to seven years, representing over 80 percent of all reported cases of HIV
infection with a known mode of transmission. HIV has already begun moving
rapidly from that sub-culture to people who have no direct contact to drugs,
often through unprotected sex.
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- Russia is wedged between opium-producing Afghanistan
and major drug markets in Western Europe, making heroin and other opiates
easily accessible. Russia's long and porous southern border, manned by
underpaid and overworked customs inspectors, border guards, and Interior
Ministry officers, is especially susceptible to drug trafficking and transport
of illicit goods. The demand for illegal drugs has increased over the past
decade, driven by a combination of factors, including the difficulties
of Russia's ongoing economic and political transition, deteriorating education
and healthcare systems, and a nationwide shortage of social services and
recovery programs for drug users.
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- Illegal drug use is especially rife among Russia's youth.
In May 2003, Russia's Minister of Education reported that 4 million young
people between the ages of 11 and 24 were using illicit drugs, and that
about a million of them were drug dependent; around the same time, an Education
Ministry survey reported that 8 percent of Russian youths bought illegal
drugs every day. Both statistical and anecdotal evidence indicate that
drug use among young people in Russia continues to climb. This trend, together
with a shortage of high-quality condoms and a lack of information about
safer sex, suggests that conditions are ripe for the virus to spread rapidly
among Russia's non-drug using youth.
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- Sex Workers
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- Sex workers constitute a second important high-risk group
with the potential to spread HIV into the general population. Since the
collapse of the Soviet Union, sex work in Russia has increased dramatically.
In Moscow, the number of professional sex workers is believed to total
between 13,000 and 30,000. In St. Petersburg, the number of full-time prostitutes
is estimated at about 8,000.
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- But sex work is not confined to those two cities. Port
communities, mining cities, and industrial centers are well-known for high
concentrations of sex workers. A recent U.S. Centers for Disease Control
and Prevention (CDC) study revealed high levels of epidemiological exposure
to sex workers in a number of cities in Saratov oblast, for example. Depending
upon the city under consideration, the researchers estimated the annual
number of sex worker contacts per 100,000 persons in the general population
to range from a low of 33,000 to a high of 730,000. If the pattern in Saratov
mirrors other regions across Russia, the implications for the spread of
HIV, as well as for other public health problems, are dire.
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- Sex workers are widely known to engage in high-risk behavior.
Leaving aside the large number of sexual partners, condom use is erratic
and there is considerable overlap among sex work and injecting drug use.
Targeted interventions in this community are essential to an effective
overall HIV strategy.
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- Prison Population
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- With nearly 900,000 people held in prisons and pre-detention
centers, Russia has one of the world's highest ratios of inmates to total
population: an estimated 1 percent of the population aged 20-64 is currently
incarcerated. According to official Ministry of Justice data, as of early
2003, over 37,000 inmates in Russian prisons and pre-detention centers
were HIV positive. This would mean that 4.1 percent of Russia's inmates
are living with HIV - a rate nearly 30 times higher than registered for
Russia's non-incarcerated population. But HIV infection rates among prisoners
are certainly even higher than that; programs for testing Russian inmates
for HIV are poorly run and coverage is inconsistent.
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- Russia's overcrowded prison system also harbors a myriad
of risk factors that facilitate the spread of HIV. According to one survey,
20 percent of Russian prisoners acknowledged injecting drugs while incarcerated;
another report, for Tyumen oblast, indicated that up to one-third of young
drug-using prisoners began using drugs in jail. Sex is also a major risk
factor for inmates: one survey of prisoners with 1.5- to 10-year sentences
reported that 85 percent had sexual encounters while in prison. The vast
majority of sexual encounters are unsafe, as condoms are generally unavailable
to prisoners.
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- The conditions and policies under which prisoners live
create a breeding ground for other infectious diseases, including drug-resistant
tuberculosis. HIV and TB have high rates of co-infection, and when prisoners
are released into the general population, they all too often carry both.
Roughly one-tenth of Russia's inmates now test positive for tuberculosis.
In short, the Russian prison system serves both as an incubator for the
spread of HIV and other infectious diseases, and also as a vehicle for
spreading HIV into the general population when inmates are released.
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- Worrisome Trends
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- In light of the dramatic rate of increase of HIV in recent
years, the prognosis for the future development of the epidemic is grim.
The total number of persons living with HIV in Russia will certainly continue
to increase for several years - even if effective prevention programs were
implemented today.
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- Although Russia's HIV epidemic has been largely concentrated
among high-risk populations, there is mounting evidence that the virus
has already begun to move beyond these groups into the general population.
As recently as 2000, 90 percent of the country's new officially registered
HIV cases were attributed to injecting drug use. By 2002, however, the
percentage of HIV cases ascribed directly to drug use fell to 36 percent,
while the number of cases attributed to heterosexual transmission rose
to over 12 percent. Another indication that the epidemic has spread more
widely into the general population is the sharp increase in the number
of babies born to women with HIV. In 2002, there were over 2,700 babies
born to HIV positive mothers, an increase of more than 230 percent over
2001.
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- Alarming trends in the incidence of curable sexually
transmitted infections (STIs) also point to the potential for HIV to spread
into the general population. STIs greatly increase the likelihood of HIV
transmission, and their presence indicates that sexually active people
are not using protection. In 2002, the reported incidence rates for a number
of STIs were many times higher in Russia than comparable figures from Western
European countries.
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- The prevalence of STIs in some ostensibly "low-risk"
populations is also remarkably high. A survey recently conducted in St.
Petersburg, for example, found that 15 percent of university students questioned
had at least one sexually transmitted disease. These trends, especially
against the background of high rates of injecting drug use among Russian
young people, suggest a very dangerous mix of risky behavior.
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- Projections for Russia's HIV/AIDS Epidemic
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- In planning an effective strategy to confront Russia's
HIV crisis, Russian policy makers must consider a range of possible medium-
and longer-term scenarios.
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- Figures 2 and 3 demonstrate the impact of HIV on Russia's
life expectancy and working age population, respectively, under three different,
but reasonable scenarios for the epidemic. The "mild" scenario
presumes that Russia's HIV prevalence peaks at 2 percent of the adult population
by 2025; the "intermediate" scenario assumes a 6 percent prevalence
rate; and the "severe" scenario assumes a 10 percent prevalence
rate.
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- Under the "mild" scenario - which some experts
suggest Russia has already reached or exceeded - Russia would have over
5 million cases of HIV infections by 2025, and over 3.4 million persons
in Russia would have died of AIDS. All gains in life expectancy would be
rolled back for 15 years, and life expectancy would be four years lower
than it would have been without HIV.
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- Under the "intermediate" scenario, a cumulative
total of 11 million people would have contracted HIV in Russia by 2025
- with 8.7 million deaths related to AIDS. The "severe" scenario
is extraordinarily grim: by these calculations, over 7 million people in
Russia would be living with HIV in 2025, and over 12 million would already
have died of AIDS.
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- These projections illustrate the concrete challenges
that HIV/AIDS represents for Russiaóchallenges that must be confronted
with decisive action. Even under the "mild" scenario, HIV would
be a horrendous humanitarian disaster for Russia, with an average of over
200,000 AIDS-related deaths each year beginning in 2010. In all cases,
the impact of HIV on Russia's labor force is strong and negative.
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- The epidemic has much broader implications for Russia
as well: by adversely impacting the health and the size of Russia's economically
active population, the HIV epidemic will exact serious costs in terms of
economic performance. Foregone productivity and economic growth due to
HIV/AIDS will not only affect living standards. By negatively impacting
the size of Russia's GDP, the epidemic will also limit Russia's economic
power - and by extension, Russia's influence on the international stage.
Even without considering the possibility of destabilizing social tensions
unleashed by the epidemic, Russia will potentially face severe adverse
consequences in the areas of national security and economic stability if
it cannot successfully control its HIV/AIDS epidemic. The numerous, multifaceted,
and complex policy implications of these trends will require a top-level,
strategic commitment of resources for years to come.
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- Copyright © 2003 Transatlantic Partners Against
AIDS. All rights reserved.
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- http://www.tpaa.net/pdf/Final%20Report_English_web.pdf
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