The HIV epidemic in Leningrad oblast is considered to be one of the worst in Russia and HIV prevalence in the region is the third highest among the 83 federal territories of the Russian Federation. The HIV incidence and its increase rates in the oblast are higher than average in entire Russia. The main route of transmission is parenteral, but it is alarming that heterosexual transmission is increasing and indicates a generalization of the HIV epidemic process in the region. The number of HIV/TB co-infected patients has also increased and the main cause of death in patients with AIDS is generalized tuberculosis. Existing HIV control measures and efforts to halt the spread of HIV-infection in Leningrad oblast are insufficient. It is necessary to strengthen the AIDS Centre and other facilities that assist people living with HIV (PLWHIV), expand human recourses, organize interdepartmental cooperation for prevention of HIV infection and drug abuse in the region.
In accordance with the UNAIDS reports, in the last decade the number of new HIV cases has gone down by almost 20%, yet the HIV infection epidemic remains the most devastating in the world. Over the thirty years of its existence, more than 33 million people have been infected with it globally. Each year about 3 million people contract this infection. In Russia the HIV infection epidemic is relatively “young” and has its own specific characteristics. At present, the epidemic situation for HIV infection in the country is characterized by an increase in the number of HIV-infected people and by the increase of incidence and mortality rates. According to the statistics from 2009, more than 500,000 HIV-infected patients are registered in the country, including 60,000 new cases of the disease. The HIV infection development in Leningrad oblast mirrors the general situation in the country, yet it also has some unique features when compared to other regions, due to the particular social, economic, geographical situation and other distinctions. This study is concerned with the analysis of the epidemic situation for HIV infection in Leningrad oblast in 1999-2009. Its goal is to determine ways to stabilize the situation as well as to identify means of improving the efficiency of preventive measures, medical check-ups and the treatment offered to HIV patients.
Materials and Methods
An assessment and detailed analysis of the HIV epidemiological situation was performed using incidence data collected during an 11-year period from 1999 to 2009. The prevailing transmission routes, age structure and major causes of death among HIV patients living in Leningrad oblast were included. A comparative analysis of HIV incidence in the oblast and in Russia was performed for the study period. The dynamics of interrelated pathogenic, clinical and social parameters including incidence of HIV, tuberculosis and drug addiction were also subject to comparative analysis. The official annual reports of the Ministry for Healthcare and Social Development of the Russian Federation and the Federal Service for Surveillance on Consumer Rights Protection and Human Well-Being (Rospotrebnadzor) that include data on HIV infection, tuberculosis and drug addiction in Leningrad oblast were the main sources of information for the epidemiological analyses.
From 1999 to 2009, the incidence of HIV infection in Leningrad oblast increased by more than 25 times from 3.2 to 86.0 per 100,000 population (Figure 1).The incidence of HIV infection in the Russian Federation grew only by three times, from 13.5 to 40.8 per 100,000 population, during the same period .
Fig. 1. HIV infection incidence in Leningrad oblast and in the Russian Federation, 1999-2009
A significant deterioration in the epidemiological situation in Leningrad oblast, as well as in Russia on the whole, was observed during the late 1990s and early 2000s. The HIV incidence increased rapidly by 37 times within this three-year period, from 3.2 (in 1999) to 117.0 (in 2001). In the Russian Federation during the same period the HIV incidence grew by 4 times from 13.5 (in 1999) to 55.4 (in 2001) . During the following years, the HIV incidence decreased and the epidemiological situation in the oblast and country remained stable until 2007. There were no significant changes in the development of the epidemic that can explain this observation. It may be a result of a so called “saturation effect” among populations of injecting drug users (IDU), i.e. the prevalence of HIV infection among IDUs reached its maximum and the highest number of HIV-infected drug users was detected . From 2007, the epidemiological situation in Leningrad oblast began to deteriorate. The HIV infection incidence increased by 1.2 times, as in the country on the whole, from 69.2 (in 2007) to 86.0 (in 2009) per 100,000 population.
During 2005-2009, the proportion of various transmission routes of HIV infection have started to change (Table 1). The frequency of cases due to parenteral transmission became irregular. From 2005-2006 the proportion of parenteral transmission decreased from 63% to 46% and then increased to 54% in 2009.
Table 1. Main HIV transmission routes in Leningrad oblast, 2005-2009
The number of heterosexually transmitted cases increased from 34.8% in 2006 to 45.0% in 2009. In 2008 it was not possible to conduct comprehensive epidemiological investigations for each HIV case in the oblast. Thus there was a high percentage of cases for which the transmission route in 2008 is not known (15%). It was especially difficult to obtain data in some of the districts where patients live in small settlements and are reluctant to contact medical workers. In such localities the HIV test coding system is imperfect and the correct reasons for the test often fail to be registered. The number of patients infected via homosexual transmission in the region is very low. In the previous five years the average proportion was only 0.3% with a maximum value of 0.7% reached in 2006. The largest proportion of HIV patients are infected parenterally as indicated by the observed correlation between new HIV cases and the use of psychoactive substances (PAS) (Figure 2). The highest number of newly registered PAS users correlated with the peak of HIV infection incidence in 2000-2001. Both values declined during 2001-2003 and remained stable in 2003-2007. During the last few years the incidence of HIV and PAS use have again increased.
Fig. 2. HIV incidence and psychoactive substance use in Leningrad oblast, 1992-2009
In the gender structure, the majority of PLWHIV in Leningrad oblast are men (Table 2). In the last 3 years, the average ratio of men and women among newly registered HIV cases remained stable at 1.3 (ranging from 1.2 to 1.4).
Table 2. Gender structure of new HIV cases in Leningrad oblast, 2007-2009
The age structure of people living with HIV in Leningrad oblast has also changed. Since 2007, the proportion of patients over the age of 30 has grown while the amount of patients of 20-29 years of age has decreased (Figure 3). The longer lifetime of people living with HIV can be explained by the broad and systematic use of antiretroviral therapy (ART) that was implemented in 2007 and also by the improved quality of medical, social, and psychological support provided.
Fig. 3. Age specific incidence of PLWHIV in Leningrad oblast, 2005-2009
In 2009, Leningrad oblast reported the third highest HIV cumulative incidence among the 83 federal territories of the Russian Federation. The rates were only higher in Samara and Irkutsk regions where the cumulative incidences were 1157.1 and 1085.3 per 100,000 population, respectively . In Leningrad oblast in 2009 the cumulative incidence was 980.5 while the average rate for Russia was 338.5 per 100,000 population . HIV infection spreads unevenly in different districts of the oblast (Figure 4). The most affected are the districts bordering the city of Saint Petersburg.
Fig. 4. HIV cumulative incidence in Leningrad oblast, 2009
By 2009 the highest HIV cumulative incidence was registered in Gatchina, Tosno and Priozersk districts with over 900 cases per 100,000 population. In 13 of 17 districts in the oblast the rate was over 500 cases per 100,000 population. The lowest HIV cumulative incidence was observed in the districts of Podporozhye and Lodeynoye Pole with up to 300 cases per 100,000 population. These are remote districts located far from Saint Petersburg and other industrial and populated cities.
A total of 1808 lethal outcomes were registered among PLWHIV in Leningrad oblast by 2010. In 291 cases the death was a result of HIV infection. In 2009, 461 lethal outcomes were registered, including 148 cases due to HIV infection. Accordingly, HIV infection with a clinical diagnosis of AIDS (32%) is the main cause of death among PLWHIV in Leningrad oblast. Homicide and suicide account for 19% of deaths among PLWHIV (Figure 5).
Fig. 5. Proportion of main causes of deaths among people living with HIV in Leningrad oblast (%), 2009
Tuberculosis that is not associated with HIV infection accounts for 12% of deaths among PLWHIV. Gastrointestinal diseases and cirrhotic hepatitis of various etiologies accounts for 5 % of the deaths. Cardiovascular diseases also account for 5% of the lethal outcomes among PLWHIV. This is noteworthy and requires more comprehensive clinical and demographic analysis. The frequency of lethal outcomes with unknown causes was 13% and is mainly due to the absence of autopsy. According to the data collected at the tuberculosis hospital in Zeleny Kholm, about 60% of deaths among AIDS patients were due to generalized tuberculosis . Tuberculosis, a socially associated disease, is frequently observed among persons with HIV. In Leningrad oblast, the incidence of tuberculosis was previously quite stable but has increased during the last three years from 69.2 in 2007 to 79.7 in 2008 and 87.6 in 2009 per 100,000 population (Figure 6). During 2006-2009 the total number of patients with HIV/TB co-infection increased by almost three times from 110 to 294 (Figure 7). The number of new cases grew from 85 in 2006 to 191 in 2008 and almost 1/3 of the patients suffering from co-infection die every year. According to our data, active tuberculosis develops in 33% of patients with HIV infection within a period of 6-7 years after an HIV-positive test result is confirmed .
Fig. 6. Incidence of HIV infection and tuberculosis in Leningrad oblast, 1999-2009
Fig. 7. Number of patients with HIV/TB co-infection in Leningrad oblast, 2006-2009
During the last decade, HIV infection has become widely spread in Russia. A range of territories are involved in the epidemic process and in an increasing number of settlements over 2% of the total population are infected with HIV. The developing HIV epidemics in Leningrad oblast and Russia in general are similar but the incidence is higher in this region. Leningrad oblast is located in the Northwestern federal territory and has area of 859,000 square kilometres and a population of more than 1,600,000 people living in 17 districts or municipalities. The region borders with Estonia, Finland, and the Republic of Karelia as well as Pskov, Novgorod, and Vologda oblasts. Together with Saint Petersburg, this oblast forms a large metropolis with a population of more than 6 million people. The size influences the characteristics of transmission of HIV infection. The registered increase in the number of people infected with HIV through heterosexual contact and the impact on the increase in HIV incidence in the oblast leaves room for discussion and requires a retrospective epidemiological investigation of each case. This is at present not possible due to the lack of specialists. However, the growing number of people infected through sexual contact is an obvious indicator that HIV is spreading beyond the relatively isolated group of IDUs into the general population. In other words, Leningrad oblast is facing a generalization of HIV infection epidemic. When psychoactive substance use and new cases of HIV infection in Leningrad oblast are compared a clear interdependence between the two parameters is noted. Sociological surveys of drug traffic in Saint Petersburg and Leningrad oblast could help to enforce anti-drug measures and contribute to the epidemic control of HIV infection in the metropolis. It is also necessary to address the spread of HIV among men having sex with men (MSM). The low proportion of cases reporting homosexual transmission route does not correspond to the real situation. A report by А. Kinsey indicates that every tenth man in the population is exclusively homosexual . Therefore it may be assumed approximately 30,000 men in Leningrad region have sex with men. According to WHO data, about 9.5% of MSM in Russia are infected with HIV. Consequently, the number of HIV-positive MSM in Leningrad oblast may amount to 3,000.
The registered increase in the number of people with HIV/TB co-infection in Leningrad oblast is not unexpected. It is well known that tuberculosis most frequently develops during the late stages of HIV infection, i.e. in 8-10 years after a person becomes infected with HIV. The HIV infection incidence reached its peak in the oblast in the early 2000s. Many persons infected with HIV during this time are now classified as AIDS patients due to absence of systematic and widely-used antiretroviral therapy.
The Centre for Prevention and Control of AIDS and Infectious Diseases (hereinafter referred to as the Centre) is the main medical institution responsible for controlling the spread of HIV in Leningrad oblast. The Centre was established in 2001 at the Republican Clinical Hospital of Infectious Diseases (RCHID) in the settlement of Ust’-Izhora. In 2006 it acquired the status of an independent state healthcare institution in the oblast. In several districts of the oblast there are 18 fiduciary infectiologists, 21 municipal screening laboratories, a reference laboratory at RCHID in Ust’-Izhora, and inter-district laboratories in Kirishi and Gatchina where immune status and viral load can be determined, and secondary and opportunistic diseases can be diagnosed. The Centre provides all aspects of HIV control in the oblast including HIV treatment, and cooperates with non-governmental organizations such as Pozitivnaya Volna (Positive Wave), Stellit (Stellite), Klyon (Maple Tree) and others. The staff members have adequate experience as a result of participation in international investigative and practical projects in cooperation with colleagues from Finland, the US and Italy. Yet the HIV epidemic in Leningrad oblast cannot be effectively controlled by medical measures alone. It requires the integration of all organizations concerned including social authorities, educational institutions, law-enforcement bodies and drug control authorities. In 2008 the Coordination Council on HIV and Tuberculosis in Leningrad oblast was established in order to support collaboration between the different authorities in order to promote HIV control efforts. Preventive measures including the promotion of healthy lifestyles and HIV prevention need to be implemented on a systematic and regular basis in the population and at educational institutions. Measures addressing prevention and change of behavioural risks related to HIV infection among drug users, commercial sex workers and other vulnerable groups are provided within short-term projects and are thus inconsistent. After projects are completed, the measures are often not sustained due to lack of financial support from the state budget.
The HIV epidemic situation in Leningrad region will not become stable before regular preventive measures are taken among the population at large and vulnerable social groups. In addition, effective collaboration between the responsible departments is essential, the range of services for people living with HIV needs to be extended, medical and social workers must receive special training regarding HIV-related issues and proper treatment must be provided for all HIV patients.
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