Elsevier

The Lancet

Volume 361, Issue 9362, 22 March 2003, Pages 1035-1044
The Lancet

Review
HIV in central and eastern Europe

https://doi.org/10.1016/S0140-6736(03)12831-0Get rights and content

Summary

We describe recent trends in the HIV epidemic and the differences between eastern and central Europe, using surveillance data, and published and unpublished reports. During the past 5 years, most countries of the former Soviet Union have been severely affected by HIV epidemics that continue to spread as a result of injecting drug use. With an estimated 1 million individuals already infected—mostly injecting drug users—and high rates of syphilis, the region may soon also face a large-scale epidemic of sexually-transmitted HIV infection. Indeed, data indicate that an HIV epidemic, fuelled by heterosexual transmission, is emerging; its expansion will depend on the size of so-called bridge populations that link high-risk groups with the general population. The lack of evidence to indicate increased rates of HIV as a result of homosexual transmission could indicate the social vulnerability of homosexual and bisexual men in the region rather than the true epidemiological picture. In view of the current levels of HIV prevalence, eastern Europe will soon be confronted with a major AIDS epidemic. By contrast, rates of HIV in central Europe remain low at present, but behaviours that promote HIV transmission are present in all countries. Improved measures to prevent further HIV spread are urgently needed.

Introduction

Although initially isolated from the global HIV pandemic by draconian Soviet restrictions on contact with foreigners and harsh social control, there has been a growing epidemic in eastern Europe since the mid 1990s. The first outbreaks were reported in 1995 among injecting drug users in Odessa and Nikolayev in southern Ukraine.1, 2 They were rapidly followed by other drug-related HIV outbreaks, notably in the Russian territory of Kaliningrad in 1996,3, 4, 5 and a few months later in other regions of the Russian Federation (Krasnodar, Rostov on Don, Tver) and in neighbouring Belarus and Republic of Moldova.6, 7, 8, 9, 10, 11 In 1999, two very large outbreaks were identified, again in the Russian Federation, in the Moscow and Irkutsk regions.12 Since then, the situation has continued to worsen rapidly, affecting more regions and countries.13 UNAIDS and WHO14, 15 recently reported that, with an estimated 1 million HIV-positive individuals at the end of 2001 compared with only 30 000 at the start of 1995, eastern Europe and Central Asia are the regions of the world with the fastest growing HIV epidemic. By contrast, in central Europe, epidemics that began in the late 1980s have remained at low levels, apart from specific outbreaks in Romania and Poland, and do not seem to be expanding.

To further understand the development and recent trends of the HIV epidemic in central and eastern Europe, we analysed HIV/AIDS surveillance data for the 27 countries of the former communist bloc, including all countries of the former Soviet Union, some of which are in Central Asia. We also reviewed published and unpublished studies and reports. We then examined the contributions of different vulnerable populations and discussed factors influencing the past increases in rates of HIV infection and the potential for future increases, taking into account the public-health response.

Section snippets

Definition of geographical areas

We searched for data on the 27 countries. This region is large and heterogeneous covering 24 million km2, and is home to a population of 413 million. We grouped the 27 countries into two geographical areas: the East region (the 15 Newly Independent States of the former Soviet Union in eastern Europe and Central Asia: Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, Uzbekistan;

Current status of the epidemic

The main trends and contrasting situation between the two regions that we have defined can best be described by data from HIV/AIDS case reporting because, despite their previously described limitations, they are the most reliable and complete data available. By the end of 2001, a cumulative total of 251 237 cases of HIV infection were reported in both the East and Centre regions (Table 1, Table 2). Of these, most (83%) were diagnosed in the East region in the past 4 years.13

Injecting drug use

The spread of HIV in the East region is closely linked with a rise in injecting drug use that developed after the collapse of the Soviet Union during the 1990s in the midst of a severe socioeconomic crisis and at the time when Afghanistan became the world's largest opium producer. This increase in opium production was paralleled by a diversification of trafficking routes through Central Asia and eastern Europe, an increase in overall trafficking of heroin from Afghanistan and surrounding

Mother-to-child transmission

Now that effective prophylactic treatment is available, mother-to-child HIV transmission should occur only very rarely, provided HIV-infected women are diagnosed before or during pregnancy. The number of HIV-infected children will depend on the prevalence of HIV among child-bearing women and on the coverage of adequate preventive interventions. With the current rates of epidemic spread in the East region, HIV prevalence in women is likely to increase sharply. In the Russian Federation, in which

Iatrogenic infections

In the past, several outbreaks of nosocomial HIV infection among children have occurred in the region, notably in Romania but also in several hospitals in southern regions of the Russian Federation.58, 59 Inadequate infection-control practices remain a matter of concern in the region. In Romania, acute hepatitis B infection among young children in the late 1990s was associated with receiving injections.60 In Georgia, shortages of disposable medical instruments, diagnostic test systems, and

Discussion and conclusions

The profound social and economic upheaval which took place in the former Soviet Union in the 1990s has resulted in a sharp increase in the incidence of substance abuse, prostitution, HIV, and other sexually transmitted infections. The HIV situation in eastern Europe cannot be analysed without considering the broader socioeconomic context within which it is evolving, because the latter influences vulnerability to HIV as well as prevention and control strategies. Rapidly declining socioeconomic

Search strategy and selection criteria

We used the EuroHIV databases on HIV/AIDS case reporting and HIV prevalence, together with data collated by the WHO regional office for Europe and UNAIDS, and unpublished reports from national and regional HIV/AIDS surveillance. We searched the literature up to May, 2002, using the appropriate MeSH terms and the explode function in PubMed, and identified grey literature (government and other institution reports) from journal articles and conference abstracts in AIDSLINE. Among substantial

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