ReviewHIV transmission and HIV prevention associated with injecting drug use in the Russian Federation
Introduction
Injecting drug use is the predominant mode of HIV transmission in eastern Europe and central Asia. A decade after HIV transmission peaked in western Europe, and since 1995, epidemics of HIV have been reported among injecting drug users (IDUs) in a number of countries or territories in eastern Europe and central Asia, including most notably, Belarus, Kazakhstan, Moldova, Russia and Ukraine, and more recently, Estonia, Latvia, Lithuania and Kyrgyzstan (Rhodes, Platt, et al., 2002). The spread of HIV among IDUs in the region has been characterised by ‘rapid’ or ‘explosive’ outbreaks (Dehne, Khodakevich, Hamers, & Schwartlander, 1999; Rhodes et al., 1999; Rhodes, Lowndes, et al., 2002). In Russia, HIV outbreaks among IDUs have been observed in over 30 cities and in 82 of the 89 Regions or Territories of the Federation, including Kaliningrad (since January 1996), Krasnodar (since February 1996), Nizhny Novgorod (since March 1996), Tumen (since April 1996), Rostov (since June 1996); Tver (since 1997), Tula (since April 1997), Irkutsk (since 1998), Moscow (since 1999) and Saint Petersburg (since 2000). Russia accounts for over 70% of all HIV infections officially registered in central, eastern European and central Asian countries (Rhodes, Platt, et al., 2002), and is one of the fastest growing HIV epidemics in the world (UNAIDS, 2002). In this paper, we seek to review recent evidence, both of trends in HIV transmission and risk behaviour and trends in HIV prevention response among IDU’s.
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Methods and data sources
This review draws on published English and Russian language research literature, international conference abstracts, international agency and country assessment reports, and centrally registered HIV surveillance data. Electronic literature searches included the following databases: Medline (OVID) and the International Bibliography of the Social Sciences. Keywords employed included: Europe, eastern, in combination with: HIV; HIV and risk; injecting; drug; prostitution; sex behaviours; sexually
Routine HIV surveillance
In the absence of targeted HIV prevalence studies among IDUs, the routine collation of HIV case reports remains the primary mode of HIV surveillance. In general, such case reports may be taken as approximate indicators of the geographic diffusion of HIV, though tend to underestimate the extent of HIV among vulnerable or hidden populations, such as IDUs (Dehne & Kobyshcha, 2000). Table 1 summarises notifications of new cases of HIV in Russia, including among IDUs. The total number of HIV
The diffusion of injecting drug use
Prior to the rapid diffusion of powdered heroin in eastern Europe since about 1997, the most commonly injected opiates in Russia were kitchen-based home-produced derivatives of poppy, including ‘chornaya’ (‘black’), ‘khimiya’ (‘chemistry’), ‘mak’ or ‘hanka’. Prior to 1998, between 70 and 95% of Russian IDUs were estimated to be regularly injecting these drugs (Dehne et al., 1999). In addition, home-produced derivatives of ephedrine and ephedrine-based medicines include a liquid methamphetamine
Receptive needle and syringe sharing
Most studies indicate that the majority of IDUs have had experience of injecting with borrowed and previously used needles and syringes. Studies in Ekaterinburg and Togliatti, for example, indicate that 82 and 84% of IDUs, respectively, have ever injected with previously used needles and syringes (Bogdanov et al., 2002; Rhodes, Lowndes, et al., 2002). As shown in Table 3, survey estimates of the proportions of IDUs reporting recent or current receptive needle and syringe sharing range from 36
Risk reduction
International studies indicate reductions in the level and frequency of needle and syringe sharing among syringe-exchange participants, and associate the legal accessibility and availability of syringe distribution with reductions in HIV transmission (Bastos & Strathdee, 2000, Des Jarlais et al., 1996; Gibson, Flynn, & Perales, 2001; Hurley, Jolley, & Kaldor, 1997). In Russia, there is a growing evidence base of evaluative and other research exploring risk reduction among IDUs. Of recent note
Historical development
The first documented projects in harm reduction in Russia were established in 1996. These included a peer-driven intervention and syringe exchange in Yaroslavl funded by the International Harm Reduction Development (IHRD) Programme of the Open Society Institute (OSI) (Sergeev et al., 1999); a short-lived mobile syringe-exchange project in Moscow, also funded by IHRD; and a street outreach, counselling and condom distribution project for IDUs (without syringe distribution) in Moscow funded by
Discussion
Recognising the relative dearth of published material exploring HIV transmission and HIV prevention associated with injecting drug use in Russia, we have provided a preliminary review of the evidence base, including that derived from Russian language sources.
Conclusion
In the context of continuing levels of risk behaviour sufficient to sustain HIV transmission alongside evidence associating Russian syringe distribution and exchange programmes with risk reduction among IDUs, we note the critical importance of policy interventions to maximise syringe distribution coverage among IDU populations. We also note the importance of strengthening the Russian evidence base by introducing studies to estimate syringe distribution coverage and its likely cost effectiveness
Acknowledgements
We are grateful to the UK Government Department for International Development for supporting this work as part of the DFID Knowledge Programme in HIV/AIDS based at Imperial College. We would also like to thank Dr. Tatiana Smolskaya for her comments on an earlier draft of this paper and Vitaly Zhumagaliev at the Open Health Institute, Moscow, for contributing data on the extent and location of harm reduction projects in Russian cities. We are also grateful to Mark Davis (City University), Katya
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