Friday, February 23, 2007

A Dual Epidemic: HIV/AIDS and Injection Drug Use in Russia

I'm Meredith Prasse.

Before 1995, the total number of HIV infections in the entire region of central and Eastern Europe, with over 450 million inhabitants, was less than 30,000. The World Health Organization reported an estimated 0.6-1.9% prevalence, between 420,000 and 1.4 million cases, of HIV/AIDS in Russia in 2003. Between 1996 and 1998 alone, Russia experienced a 100-fold increase in new HIV infections, demonstrating the rapid onset of the epidemic in this region. Well over 70% of all HIV cases in Russia occur in injection drug users (IDUs), demonstrating the widespread exercise of unsafe drug-using practices among the IDU population in Russia. Sadly, only 10% of HIV-infected Russian IDUs currently receive HIV combination therapy, and only 15% of HIV-positive Russians receiving therapy are IDUs.

An epidemic of drug use is occurring alongside the HIV/AIDS epidemic in Russia. While the epidemic of injection drug use in Russia cannot be attributed to a single factor, there was a significant rise in drug use following the collapse of the Soviet Union. WHO estimates that between 1.5 and 3.5 million Russians are IDUs, and the prevalence of HIV in the drug-using population approaches 65% in some Russian cities, further demonstrating the connection between drug use and HIV in Russia. Between 1990 and 2002, the number of first-time drug users referred to treatment centers increased 6.5-fold, while the number of drug-associated deaths increased 5-fold between 1999 and 2000.

The challenges facing the Russian HIV/AIDS epidemic are multifaceted. An estimated 30-40% of IDUs in Russia use non-sterile needles or share needles, demonstrating the widespread unsafe drug use in Russia. Many IDUs reportedly re-fill their syringes by front-loading from the dealers’ syringes, and many dealers are IDUs themselves who inject from that very supply. During the drug preparation process, dealers in several different Russian cities have also reported adding blood to the drug solution as a ‘cleansing’ process, believing that the blood neutralizes toxic substances used to produce the drugs.
There are also significant legal and political dilemmas which complicate the Russian HIV/AIDS epidemic in IDUs. A combination of harsh drug policies and regular harassment by the police force pushes IDUs underground and decreases their chances of accessing preventive resources or care in drug treatment facilities. The synonymously corrupt Russian police arrests IDUs for possession of minimal amounts of narcotics in order to fill quotas. As a result, drug users refrain from seeking treatment or accessing clean needles in fear of incarceration or simply being registered as a drug user. IDUs that access formal treatment centers are officially registered and monitored by that facility for five years, and this official registration can have further negative repercussions such as restrictions on employment, drivers’ licenses, and military service. While treatment for drug dependence is an effective way to both eliminate drug dependence and decrease the risk of contracting HIV, the distrust in drug treatment services has resulted in low utilization of these resources by IDUs. Another legal dilemma for IDUs is that methadone, a common substitution for heroine users and an important part of HIV prevention for heroine users elsewhere, is banned for treatment in Russia.

While IDUs comprise the majority of the at-risk population in Russia, the threat to non-IDUs is on the rise. A majority of IDUs in Russia are young heterosexual men. These men have the potential to spread HIV to their partners: commercial sex workers, girlfriends, wives, etc., many who do not have the power or awareness to demand condom usage. In addition, commercial sex work is on the rise in numerous Russian cities, and the overlap between injection drug use and commercial sex work is high. It is estimated that between 15 and 50% of female IDUs practice commercial sex work, and many of them do so as a means of obtaining drugs. HIV transmission from sex workers to their clients is high, and these male clients may subsequently infect their non-IDU sex partners. Thus, IDUs and sex workers act as a bridge for sexual HIV transmission between IDUs and non-IDUs in Russia, facilitating a more widespread epidemic.

In the face of the continually increasing rates of drug use and HIV infection, the Russian government needs to implement policy changes to slow these increasing rates. This dual epidemic can be fought on many different fronts. Primarily, the government must increase support for safe needle exchange programs to reduce the spread of HIV among the IDU population. In addition, the ban on methadone-substitution therapy for heroine users should be lifted to encourage treatment options and reduce needle use. More generally, the government needs to put more focus on drug prevention programs. Future HIV prevention strategies targeting IDUs should include sexual risk reduction to reduce the potential spread between the IDU and non-IDU populations. With such alarmingly high rates of HIV infection among the IDU population, this problem cannot be ignored. The longer it is disregarded, the more this epidemic will seep into the non-IDU sectors of Russian society, facilitating an epidemic with a wider scope and greater force.

Works Cited
Bobrova, Natalia, Tim Rhodes, Robert Power, Ron Alcorn, Elena Neifeld, Nikolai Krasiukov, Natalia Latyshevskaia, and Svetlana Maksimova. “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities.” Drug and Alcohol Dependence 82 (2006): S57-S63.
Dehne, Karl L., Lev Khodakevich, Francoise F. Hamers, and Bernhard Schwartlander. “The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making.” AIDS 13 (1999): 741-749.
Human Rights Watch. “Russia: harsh drug policies fuel AIDS epidemic.” Available at Accessed on 16 November 2006. Human Rights Watch: 28 April 2004.
Kalichman, Seth C., Jeffrey A. Kelly, Kathleen J. Koslov, P Andrei, Alla Shaboltas, and Juliana Granskaya. “The emerging AIDS crisis in Russia: review of enabling factors and prevention needs.” International Journal of STD & AIDS 11 (February 2000): 71-75.
Lowndes, Catherine M., Michel Alary, and Lucy Platt. “Injection drug use, commercial sex work, and the HIV/STI epidemic in the Russian Federation.” Sexually Transmitted Diseases 30 (January 2003): 46-8.
Luo, Robert F. and Joseph Cofrancesco Jr. “Injection drug use and HIV transmission in Russia.” AIDS 20 (2006): 935-936.
Rhodes, Tim, Lucy Platt, et. al. “Prevalence of HIV, hepatitis C, and syphilis among injecting drug users in Russia: a multi-city study.” Addiction 101 (February 2006): 252-266.
Shaboltas, Alla V., Olga V. Toussova, et. al. “HIV prevalence, sociodemographic, and behavioral correlates and recruitment methods among injection drug users in St. Petersburg, Russia.” Journal of Acquired Immune Deficiency Syndrome 41 (15 April 2006): 657-662.
World Health Organization. “Summary Country Profile for HIV/AIDS Treatment Scale Up: Russian Federation.” Available at Accessed on November 16, 2006. WHO 2005.

Friday, February 16, 2007

Male Circumcision and HIV/AIDS

“When is it appropriate for public health practice to be on the side of an intervention that causes bodily injury?” (Franco)

I'm Erika Larson.

That is the question McGill’s Professor of Epidemiology, Eduardo Franco, asked when addressing circumcision as a possible method of reducing HIV prevalence. Circumcision has historically caused a polarizing debate across sectors of society including the pious, and the hygienic. Health workers have generally abstained from taking a side. However, new evidence that circumcision reduces infectivity of HIV may alter this precedent.

A recent study in the Journal of Infectious Diseases, Baeten et al. explore “Female to Male Infectivity of HIV-1 among Circumcised and Uncircumcised” in a cohort of Kenyan men. Unlike previous studies which did not isolate behavioral practices, this analysis designates per-sex act probabilities of HIV-1 transmission between circumcised and uncircumcised men.

Between 1993 and 1997, 745 Kenyan men, employed by six trucking companies around the Mombasa area, were recruited. After pre-counseling and informed consent, these men were examined for circumcision status, STD infection, and HIV-1 seropositivity using the ELISA antibody test. Follow-up visits included detailed accounts of sexual encounters and condom use. Each man attended a median of 4 follow-up visits over the span of 400 days. Risk reduction counseling and provision of free condoms accompanied follow-up visits.

Of the 95 uncircumcised men (13%), 11 experienced sercoconversion. Of the 650 circumcised men (87%), 32 seroconverted. Though the majority engaged in sexual activity with their wives, many were involved in extramarital sexual contact. The median number of sex acts per month (4.0) did not vary between circumcised and uncircumcised men. By using surveillance data to estimate prevalence for potential partners (wives, casual partners, and prostitutes), the researchers found an overall probability of acquiring HIV-1 through a single sex act was .0063. Female to male infectivity was higher for uncircumcised men than circumcised men (.0128 vs. .0051). Uncircumcised men were found to have over a 2-fold increased risk of HIV-1 infectivity per sex act.

Because the study could not trace the infection status or disease status of partners, some variants could not be isolated. However, ethnicity, occupation, and sexual risk behavior were statistically isolated. All results still revealed that uncircumcised men were at a higher risk for contracting HIV. The biological factors that cause this discrepancy could be the result of the thick skin that develops after circumcision which prevents HIV from targeting Langerhans cells.

Another study by French and South African researchers found results so dramatic that the control group was given the option to undergo the procedure. New research has created a wave of optimism in the scientific community. Dr. Seth Berkley, president of the International AIDS Vaccine Initiative, stated circumcision would be “an intervention that works over a person’s lifetime and could reduce HIV in a community setting.” Questions of acceptance as a risk-reduction policy were appeased in a recent South African study. In a survey of uncircumcised men, 70% stated they would undergo the procedure if it “proved to protect against sexually transmitted diseases.”

However optimism of community acceptance is marred by a false sense of security that circumcision could create. Increased risk behavior on the part of circumcised men could counter-act the benefits. For example 30% of uncircumcised men and 18% of circumcised men believed that the procedure would allow them to safely engage in sex with multiple partners.

Though we have already seen considerable risk-taking in prevention policy with needle exchange programs and safe injection facilities, circumcision continues to push the envelope on ethical approaches. Can we promote circumcision as a global policy to help weaken the horrifying forces of HIV? Is it feasible to pursue a worldwide circumcision effort especially in countries that rely on traditional practices (whose circumcision procedures may increase HIV-risk)? How can we prevent the unintentional consequences of viewing circumcision as a cure and the abandonment of safe-sex practices? Though circumcision does not affect HIV prevalence in men who have sex with men or IV drug users, it has huge possibilities on the African continent where heterosexual contact is the primary mode of transmission.

Friday, February 09, 2007

The Links between HIV/AIDS and National Security

I'm Rebecca Jameson

In July of 2000, the UN Security Council passed Resolution 1308 stipulating that HIV poses a risk to the stability and security of the nations of the world. Since then, there has been considerable debate regarding the relationship between the AIDS pandemic and national security. According to expert analysts, the security implications of HIV’s rapid spread in Africa and other regions must be taken far more seriously by the industrialized West.
One concern expressed by security analysts has been the impact of HIV on individuals critical to the maintenance of state and international security: namely, soldiers and peacekeepers. AIDS is now the leading cause of death in military and police forces in some African countries, accounting for more than half of in-service mortality. The loss of highly trained, professional soldiers is not limited to Africa. Trained soldiers are difficult and expensive to replace, and their absence interrupts the training of younger recruits. Armed forces that rely wholly or partially on conscripts face a decreasing pool of healthy recruits as HIV continues to spread. The strategic impact of high HIV prevalence on the armed forces is complex and involves other country-specific factors as well.
There is growing evidence that the AIDS pandemic poses increasing challenges for the conduct of peacekeeping operations. These challenges include the spread of HIV by peacekeepers, the reduced ability of countries to contribute peacekeepers, and the decrease in willingness of some countries to accept peacekeepers who may pose a disease risk to them.
Security analysts also correlate high rates of HIV infection with state instability and failure, particularly in sub-Saharan African nations. The erosion of elite populations, political leadership and skilled labor forces undermines economic growth and exacerbates social tensions. Some argue that the growing number of children orphaned by AIDS is contributing to an impoverished orphan cohort that is vulnerable to exploitation and radicalization. Even though the involvement of HIV/AIDS in state failure remains unproven and is probably indirect, the perceived linkage has propelled regions once considered “peripheral” to Western security interests into national security agendas.
The impact of the HIV/AIDS pandemic on strategically important states is another major security concern. Analysts warn that a “second wave” of HIV could potentially destabilize powerful countries and regions that are critical to the US and, by extension, to global strategic interests. Particular emphasis has been placed on the effects of the worsening pandemic in Russia, India, and China, each of which has been declared a nuclear state. The security impact of HIV in these countries may not be immediate, but increased instability in any large and strategically significant state would have major economic, political and military consequences around the world.
Although arguments linking HIV/AIDS to national security have helped to elevate the disease to the highest levels of international politics, it is also important to recognize that there are a number of potential risks in adopting a national security approach to combat the pandemic. An inappropriate redirection of HIV/AIDS resources toward strategically important countries or those supportive of the “War on Terror” is one possible outcome of such a focus. Strengthening the evidence of linkages between the AIDS pandemic and national security is essential for successfully negotiating these risks and ensuring that the public health–national security nexus benefits the fight against HIV/AIDS.

Friday, February 02, 2007

History of HIV/AIDS in the United States

In a speech given on December 1, 2006, World AIDS Day, Kofi Annan declared HIV/AIDS to be the greatest challenge of our generation. This dreaded infectious disease has claimed the lives of over 25 million people worldwide and infected 40 million more. In the United States alone, 1.2 million are infected with the HIV virus and more than 500,000 have died. No virus has been as well studied or understood as the human immunodeficiency virus, yet we are far from controlling this pandemic.

When the first reference to AIDS was published in the CDC’s Morbidity and Mortality Weekly Report on June 5, 1981, physicians were taken aback by the presence of pneumocystis pneumonia in five previously healthy young men. As more and more cases of unusual opportunistic infections were identified, the medical community felt helpless in the face of this challenge. No one had any idea what was causing this disease, how it was transmitted, or how it could be treated.
Before long, pioneers in dealing with this disease discovered that it was transmitted through sexual contact, blood products, and needle sharing and could begin to discourage people from behavior that put them at risk. HIV was identified as the disease-causing agent in early 1984. The next year, the first test to detect antibodies to HIV was developed and the US blood supply was declared to be free of contamination. The numbers of new HIV infections in the US reached their height in the 1980’s at approximately 160,000. Since the 90’s, however, prevention and education efforts have stabilized infection rates around 40,000.

Doctors had nothing to offer their patients until AZT, a nucleoside analog, was approved by the FDA in 1987. By the end of the decade, the first candidate vaccine began testing, the first comprehensive needle exchange program was established, and the Americans with Disabilities Act was expanded to include people living with HIV/AIDS. The CDC announced measures that could be taken to prevent HIV infection and to avoid some of the opportunistic infections common among people with AIDS.
While they offered hope, none of these efforts really changed the reality for people living with the disease, and by 1994-1995, AIDS was the leading cause of death among Americans aged 25 to 44. The death sentence for AIDS patients was finally lifted in 1995 when highly active antiretroviral therapy was introduced with the first protease inhibitor, saquinavir. The following year, the FDA approved the first non-nucleoside reverse transcriptase inhibitor, nevirapine, and a viral load test to measure levels of HIV in the body. Since then, these developments have led to a 70% reduction in AIDS-related deaths.
While new treatments have revolutionized the face of the AIDS epidemic, drastic changes in epidemiology and populations infected have altered the way people view the disease. Originally seen as a highly stigmatized disease of the gay community and feared for its mystery and lethality, AIDS is now recognized as a controllable disease that preys on men, women, and children alike. Homosexual contact remains the highest mode of transmission in the US, but heterosexual contact has grown significantly as a mode of transmission. Women constituted 8% of new HIV cases in 1985, but rose to account for 27% of new cases in 2005. HIV is slowly becoming a plague of the minorities. Blacks disproportionately constitute over half of new HIV infections while the incidence among whites is decreasing.

Despite the many breakthroughs that have been made to alter the HIV epidemic, many challenges remain. Stigma still persists as a major debilitating factor of this illness. Over a quarter of a million people are living with HIV but do not know they are infected. While it is no longer the leading killer, AIDS remains the sixth leading cause of death in this country. There are currently 29 drugs on the FDA’s list of drugs approved for the treatment of HIV/AIDS, but a cure or an effective preventative vaccine remain elusive. The American public finally realized that this disease could not be ignored and has recently embraced it more than ever before. Billions of dollars have been allocated towards HIV programs in the US and abroad. Nonetheless, HIV/AIDS will continue to pose the greatest challenge to our generation as we strive to halt transmission, provide diagnosis and treatment to those in need, and develop a cure to this deadly virus.

Thanks for listening,

Lauren Finley