Until the mid-1990s, most of the countries of the former Soviet Union appeared to have been spared the worst of the HIV epidemic. Mass screening of blood samples from people whose behaviour put them at risk of infection showed extremely low levels of HIV, right up to 1994. At that time the whole of Eastern Europe put together had around 30,000 infections among its 450 million people, Western Europe had over 15 times as many cases, while in sub-Saharan Africa over 400 times as many people were living with the virus.
The AIDS epidemic in Eastern Europe and Central Asia now shows no signs of declining. Some 210,000 people were infected with HIV in 2004, bringing the total number of people living with the virus to 1.4 million. AIDS claimed 60,000 lives in the past year.
Worst affected are the Russian Federation, Ukraine, and the Baltic states (Estonia, Latvia, and Lithuania), but HIV continues to spread in Belarus, Moldova and Kazakhstan, while more recent epidemics are now evident in Kyrgyzstan and Uzbekistan. It is estimated that around 860,000 people aged 15-49 were living with HIV in the Russian Federation at the end of 2003 (though estimates vary widely).
Driving these epidemics is widespread risky behaviour - injecting drug use and unsafe sex - among young people. Extraordinarily large numbers of young people regularly or irregularly engage in injecting drug use. This is reflected in increasing HIV prevalence among injecting drug users throughout the former Soviet Union.
In many countries of the former Soviet Union, such as the Russian Federation, Ukraine and Belarus, the fight against the epidemic is being waged against a complicated backdrop. Socio-economic instability in the region is fuelling drug use and commercial sex, and thus increasing the spread of HIV. On a more positive note, however, political and legal reforms are creating more effective avenues to HIV prevention. For instance, instead of relying on ineffective mass screening of the population to track and control HIV, most countries are using a range of channels to inform and educate their citizens about the virus. Also, the region is increasingly turning to proper HIV surveillance in sentinel populations, for example, in sex workers, pregnant women, injecting drug users, or people with a sexually transmitted infection.
HIV prevalence continues to rise in the Russian Federation, which remains saddled with the worst epidemic in this region. By the end of 2002, a total of 246,285 people had been diagnosed with HIV. More than a fifth (50,529) of that total was added in 2003 alone, indicating that the epidemic is growing at a frightening rate. Moreover, these reported cases almost certainly underestimate the number of people living with HIV.
Most of these infections are occurring through the use of contaminated equipment when injecting drugs, with young men bearing the epidemic's brunt. But another striking pattern is now evident. Women account for an increasing share of newly diagnosed HIV infections - 33% in 2002, compared to 24% a year earlier. One consequence is a sharp rise in mother-to child transmission of HIV. These patterns are most evident in regions where the epidemic took hold several years ago, such as Kalingrad (in the west of the country) and Krasnodar (in the south-west). They indicate the onset of a new stage in the epidemic in parts of the country, where the sexual spread of the virus is becoming a more prominent feature. Because most injecting drug users are young and sexually active, a significant share of new injections is occurring though sexual transmission (often when injecting drug users or their HIV-infected partners engage in unsafe sex).
Although advancing steadily, the Russian Federation's epidemic is still in its early stages. HIV has been detected in 88 of the country's 89 administrative territories, but it is spreading unevenly across this country. In at least 9 territories, serious epidemics are under way, and the virus has gained a firm foothold in a further 11 territories.
In Ukraine, the number of diagnosed infections has jumped from virtually zero before 1995 to around 20,000 a year from 1996 onwards, about 80% of the infections occurring in injecting drug users. A total of more than 57,140 people had been officially diagnosed with HIV by the end of 2002. Belarus has been affected by the same trends in the HIV epidemic as the other countries in the region. By the end of 2002, Belarus had had a total of 5,101 people diagnosed with HIV.
Although overall numbers of infections remain low, HIV spread continues at an alarming pace in the Baltic States. At 2,528 in 2002, the total number of HIV diagnoses in Latvia has risen five-fold since 1999. Just four years ago, Estonia reported 12 new HIV cases: in 2002, 899 people were newly diagnosed with the virus. Lithuania is on a similar path. There, the 72 new HIV cases detected in 2001 increased more than five-fold in 2002. Lithuania appears to be facing two distinct epidemics - one affecting mainly injecting drug users in regions bordering Kalingrad (Russia) and the other spreading among men who have sex with men in Vilnius.
The most recent outbreaks in the region are to be found in Central Asia, where reported HIV infections have grown dramatically from 88 in 1995 to 5,458 in 2002. This is mainly due to the sharp rise in infections recorded in Kazakhstan, Kyrgyzstan and Uzbekistan. HIV has now spread to all regions of Kazakhstan, while the majority of cases reported in Kyrgyzstan are concentrated in the Osh region, which serves as a drug transit route for neighbouring countries. Given that the five Central Asian republics are located on both sides of major drug trafficking routes into the Russia federation and Europe, it is no surprise that the majority of infections currently are related to injecting drug use. Indeed, in some parts, heroin is now believed to be cheaper than alcohol. As elsewhere in the region, young people are the worst affected, with those on the margins of the economy particularly vulnerable. In Kazakhstan, for example, three quarters of people diagnosed with HIV were unemployed.
Young people predominate in this region among reported HIV cases. In Ukraine, 25% of those diagnosed with HIV are younger than 20, in Belarus 60% of them are aged 15-24, while in Kazakhstan and Kyrgyzstan upwards of 70% of HIV-positive persons are under 30 years of age. In the Russian Federation, 80% of HIV cases due to injecting drug use are in young persons under 30. Overall, more than 80% of people who are HIV-positive in this region have not yet turned 30, in contrast to the situation in western Europe and the USA, where only 30% of the reported cases are among people under 29 years of age.
Condom use is generally low among young people, including those at highest risk of HIV transmission in Eastern Europe and Central Asia. According to one survey in the Russian Federation, fewer than half of teenagers aged 16-20 used condoms when having sex with casual partners.
By some estimates there could be as many as 3 million injecting drug users in the Russian Federation alone, more than 600,000 in Ukraine and up to 200,000 in Kazakhstan. In Estonia and Latvia, it has been estimated that up to 1% of the adult population injects drugs while in Kyrgyzstan, that figure could approach 2%.
Most of these drugs users are male and many are really young - in St Petersburg, studies found that 30% of them were under 19 years of age, while in Ukraine, 20% were still in their teens. A survey in Moscow youth aged 15-18 found that 12% of the males had injected drugs. Overall up to 25% of injecting drug use are estimated to be under 20 years of age across Eastern Europe and Central Asia. The use of unclean equipment, often through sharing of drug injecting equipment, remains the norm. In Moldova for example, an estimated 80% of users share injecting equipment (often to affirm trust towards other users), while one Moscow sample found that 75% of users had shared injecting equipment.
Sharing needles and other injecting equipment with an infected person is a highly efficient way of transmitting HIV. A needle carrying infected blood can catapult the virus directly into the bloodstream of an uninfected person. So where sharing of unsterilized needles is common, the virus will spread very rapidly through a pool of drug injectors. It is believed that HIV was first introduced into the drug-injecting population of Ukraine as late as 1995. Three years later, the country had become the epicentre of infection in Eastern Europe. Indeed, the presence of different subtypes of the virus among Ukrainian drug users suggests that HIV may have been introduced simultaneously from several parts of the world.
For further information, see our web page HIV prevention & injecting drug use.
Injecting drugs such as heroin is frowned upon in every society; in most countries it is illegal. Because of this, drug injectors - often young people at a vulnerable stage in their lives - are driven underground and do not come forward for help or information, even where it is available. Clearly, if fewer people inject drugs, fewer people will be at risk of being infected through unsafe injecting. Programmes to help users give up drugs are vital, not just because they can reduce transmission of HIV but because they can help people to improve their health and realize their full potential in other ways.
Methadone substitution and a switch away from injecting to safer methods of drug taking, such as chewing or smoking, will also reduce the risk of HIV infection. But for people who cannot give up injecting, simple measures to sterilize needles can significantly reduce the dangers, including the HIV risk. Unfortunately, support for such measures is often weak, even though they have been shown to be very effective in reducing the spread of HIV.
The Eastern European countries currently experiencing the initial boom of both injecting drug use and HIV may find they can learn from the experience of neighbours where the problem is longer established. In Poland, for instance, HIV infections among drug injectors have been recorded since the late 1980s. Initiatives to reduce needle sharing and to increase the use of simple preventive techniques such as sterilizing needles with bleach have brought recorded new infections among drug users down by half since a peak of over 650 a year in 1990.
People who inject drugs in Eastern Europe appear to face an additional risk that is not commonly seen in other industrialized countries. Anecdotal evidence suggests that drug-takers preparing opiates in some parts of the region drop fresh blood into the solution as a way of absorbing toxins commonly found in home-produced drugs. If the blood is infected with HIV, then all the injectors drawing drug solution from that batch can become infected, even if they are using sterilized injecting equipment.
In the countries of the former Soviet Union and Eastern Europe, there is a need for more vigorous and comprehensive response. This response should include ways to reduce the vulnerability of young people, reduce drug injecting and risky sexual behaviour. To do this will mean providing greater access to information, as well as to prevention tools and services. Harm reduction forms a cornerstone of such a comprehensive response, and should be broadened quickly to address the needs of young injecting drug users who face immediate and high risks of HIV infection. Special attention should be paid also to their mainly female sexual partners, to men who have sex with men and to the young women and men who engage in sex work. The prevention of mother-to child transmission is a new and urgent priority. But the growing treatment and care need of people living with HIV can no longer be overlooked.
For more Eastern European HIV & AIDS statistics, see our European summary.
Last updated August 25, 2005