HIV infection is a notifiable disease in all the countries in the region. In the Nordic and the Baltic countries, clinicians (and in some countries the laboratories) report anonymously newly diagnosed HIV infections to a national HIV database. Codes are used for detection of duplicate reports. In Russia, diagnosed HIV infections are generally reported by name, although anonymous testing is possible in most major cities. All the countries report only laboratory confirmed cases. For regions in Northwest Russia, cases diagnosed in military and penitentiary settings are not included in the officially supplied data.
Figure 4. Number of cases of newly diagnosed HIV infection notified in 2003 per 100 000 population (1).
During the 1990s and until early 2000s the Nordic countries experienced stable and comparatively low figures for newly diagnosed HIV infections, with exception of Finland who reported an outbreak of HIV in intravenous drug users in 1999-2000. In the Nordic countries, spread of HIV is relatively more common among men who have sex with men than among heterosexuals. However, the majority of cases diagnosed in the Nordic countries are among persons immigrating from highly endemic areas who were infected before arriving to their new countries. In 2003, this group constituted in Denmark 34%, in Finland 29%, in Iceland 83%, in Norway 60% and in Sweden 69% of the total number of reported cases (5). The majority of the HIV-infected immigrants arrive from Sub-Saharan Africa, but an increasing number has in the last few years arrived from Southeast-Asia.
In 2002-2003, an increase in newly diagnosed HIV cases was observed in Norway and Sweden, and also to a lesser degree in Denmark. This increase was due to a rise in numbers of newly infected men who have sex with men, and more HIV infected immigrants arriving to the Nordic countries. The HIV incidence rates among intravenous drug users remain low and stable in all the Nordic countries. It is possible that in the near future persons that immigrated from countries with higher disease burden will represent the largest group of people living with HIV/AIDS in the Nordic countries. The numbers of diagnosed AIDS cases have decreased dramatically in the Nordic countries since 1995 due to introduction of improved antiviral therapy.
Figure 5. Number of cases of newly diagnosed HIV infections notified per 100 000 population 1999-2003 by groups of countries or regions (1). Komi, Pskov, Novgorod and Vologda regions not included.
The epidemiological situation of HIV/AIDS in Northwest Russia and the Baltic states differs dramatically from that in the Nordic countries.
In Russia, a sharp rise of newly diagnosed HIV cases started in 1998, especially in the Northwest region, and a peak was observed in 2001. The decrease in reported cases in 2002 and 2003 was mainly seen among drug users. In Northwest Russia, the highest incidence of newly diagnosed cases of HIV is still found in the Saint Petersburg, Leningrad, Murmansk and Kaliningrad regions. No cases of HIV infection have so far been diagnosed in Nenets autonomous area. Intravenous drug users have dominated strongly among the cases since the start of the epidemic and this trend continues. In 2003, 76% of all newly diagnosed cases with known transmission route in Russia were associated with intravenous drug use (6).
An increasing proportion of the newly diagnosed cases of HIV occur among women and children. It is uncertain if this increase reflects the start of a heterosexual epidemic in the general population, or if these cases are in drug users or sex partners of infected drug users. HIV infection among inmates in prisons in Northwest Russia is an increasing problem. Men who have sex with men do currently not account for a large proportion of total cases in Northwest Russia, but stigmatisation faced by men who have sex with men in Russia may lead to underreporting of this transmission route. The high incidence of other sexual transmitted infections in Northwest Russia represents a potential risk factor for wider heterosexual spread. As of September 2004, 41 898 cases of newly diagnosed HIV infection have been reported in Northwest Russia (7).
In the Baltic countries, the HIV situation is very similar to the situation in Northwest Russia. Estonia is one of the countries with the highest HIV prevalence rates in WHO European region. More than 3000 cases have been reported in the country by the end of 2003. Ninety percentages of the infections are among drug users, especially in the eastern part of the country bordering Russia. About 75% of the cases are under the age of 25. Many cases have been diagnosed in prisons (26% of all cases in 2001). An increasing number of men who have sex with men are diagnosed with HIV in Estonia (6).
Since 1998, Latvia has experienced a rapid increase in the number of infected drug users, and 30% of the newly diagnosed HIV positives were diagnosed in prisons. A total of 2836 cases of HIV have been reported by the end of May 2004. Seventy-two percentages of cases were among drug users and 4% were among men who have sex with men (6).
Lithuania has by April 2004 reported only 873 cases of HIV infection. A large increase in newly reported HIV cases occurred as recently as 2002, due to a major outbreak in a prison. The main risk groups in the country are drug users and to lesser extent men who have sex with men (6). The available data do not support that a generalised heterosexual HIV epidemic is present in the Baltic countries.
The HIV situation seems to have improved during the last few years in both Northwest Russia and the Baltic countries with fewer newly diagnosed cases of HIV infection (figure 5). A combination of effective preventive measures and decrease in numbers of susceptible drug users may have contributed to this improvement. In addition, the decrease in cases can partly be attributed to the decrease of the number of HIV tests performed. The total number of people living with HIV or AIDS in the entire region is in 2003 estimated to be around 100 000; Northwest Russia 70 000, Baltic countries 16 700, Nordic countries 12 700 (6).
Over the last few years, there has been a marked increase in the number of seroprevalence studies among drug users in the eastern part of the region. The results of these studies vary depending on the population of drug users examined. Recent studies have shown the following HIV prevalence rates in drug users; St. Petersburg 35% (2001), Estonia 6.2% (2002), Riga, Latvia 22% (2003), Lithuania 2.4% (2003) and Oslo, Norway 1.2% (2002) (5).
A major challenge is to secure proper antiviral treatment for the HIV patients, particularly for pregnant HIV positive women. The high costs of treatment and access to treatment in prisons have so far been two main obstacles, especially in Northwest Russia. In addition, lack of outreach activity among risk groups and lack of social support and the societys attitude towards HIV-infected persons are major problems in Northwest Russia.
HIV prevention measures are primarily aimed at reducing risk of transmission through sexual contact and intravenous drug use. In addition, reducing the risk of mother-to-child and nosocomial transmission are also important measures. In the Nordic countries much emphasis have been put on the triad of offering free HIV-testing and screening of pregnant women, offering adequate treatment for a limited cost to patients, and active case-finding around each newly diagnosed case.
The highest number of HIV tests in the region (excluding testing of blood donors) was in 2003 performed in Russia with 126.3 tests per 1000 population, Estonia 43.4 tests per 1000 population and Norway 40.4 tests per 1000 population (5). During the last few years, the number of tests performed in Russia has been greatly reduced and less then 10% of the general population is now screened annually. Persons admitted to the penitentiary systems are usually tested for HIV in the entire region.
Generally, it is important to raise the level of awareness and knowledge of the disease in the general population, and to target information to various high-risk groups. Promotion of safe sex practices with availability of condoms is an essential preventive measure in controlling HIV spread. Prevention among high-risk groups like drug users relies on information campaigns and implementation of general measures to reduce drug abuse, and introducing harm reduction by ensuring clean needles and syringes to drug users. Clean needles and syringes are available at pharmacies in the entire region, though in Sweden needles can only be obtained through a doctors prescription. Local health authorities in the entire region, except for Iceland and Sweden, have introduced free needle programmes, needle exchange programmes or both. In Finland, regional health authorities are obliged by law to set up needle exchange programmes. More than 2 million clean needles and syringes are each year distributed free of charge in Oslo, Norway. Easy access to clean needles and injection equipment can still be a problem in some areas in Northwest Russia, and some of these harm reduction programmes often get in conflict with the local police.
Local Aids centres financed by central and local authorities have been set up in the Baltic countries and the various regions in Northwest Russia. Similar Aids centres set up in the Nordic countries in the 1980s have mostly been closed down and are now a part of the general local health services.