The determinants of the spread of HIV among injection drug addicts in Ukraine

The main tendencies in the development of drug addiction in the Ukraine, the dynamics of the spread of HIV among drug addicts introducing drugs intravenously, epidemiological data on HIV, AIDS and drug addiction, as well as prognoses on the development of HIV infection are presented. Since 1995 the number of HIV-infected persons grew 34-fold, the number of cases of HIV infection resulting from the intravenous use drugs rose to 70% simultaneously with the rise (about 34-fold) of the number of persons infected with HIV through sexual contacts (about 13 fold). In 1996-1997 such tendency increased. On the whole, the proportion of drug addicts introducing drugs by intravenous injection was 83% in the Ukraine. By April 1, 1998, official registration covered 18,800 HIV-infected persons, including 270 foreign nationals, as well as 499 AIDS patients, including 487 Ukrainian citizens, among them 28 children. Out of 18,800 HIV-infected persons, 78.3% were drug addicts, most of them young people aged 15-30 years; about 18% were young people under 20 years of age, 80% being males. According to the model the rapid spread of HIV from the group of drug addicts to the heterosexual population, the total number of HIV-infected persons reaching 1,500,000 is expected in the country by 2014.     

A strategy for the control of HIV infection and viral hepatitides against the background of the narcotic abuse epidemic

The presence of the epidemic of drug addiction in the Russian Federation is stated: for the recent 10 years the number of drug addicts increased 3.5-fold. The questioning of several thousand drug addicts has revealed that 60% of them have hepatitis B, 80% have hepatitis C, 10% have syphilis. The strategy of controlling HIV infection among drug addicts is proposed. It includes, in the first place, the prevention of the secondary infection from HIV-infected addicts; in the second place, the detection of HIV-infected persons in groups of drug addicts, difficult to establish contacts with; in the third place, the primary prophylaxis within the program "Harm reduction" in the most susceptible groups of drug addicts. The thesis that the prevention of HIV infection must become the prevention of drug addiction by rendering multi-stage assistance to HIV-infected persons, including mainly drug addicts, is substantiated.     

An analysis of an outbreak of HIV infection in the city of Svetlogorsk, the Republic of Byelarus, among persons using injected narcotics

The examination of all persons suspected in the use narcotics (including suppliers and vendors of drugs) in Svetlogorsk (Belarus) for the presence of antibodies to HIV revealed 811 cases of HIV infection, i.e. 1% of the whole population was found to be infected by HIV. More than 90% of all HIV-infected persons were drug addicts introducing narcotic intravenously; young people aged 18 to 29 years constituted 81% (of these, 76% were males and 24% were females). The rapid spread of HIV was caused by the use of a ready-made HIV-infected drug which had been supplied for sale and could have been infected in the process of manufacture or packing.     

The realization of the concept of Harm Reduction in Russia

By the present moment cases of HIV infection among injecting narcotic users (INU) have been registered in more than 100 countries. To prevent HIV infection, the program "Harm Reduction" has been developed in Britain; the program states that the prevention of HIV infection must be considered more important than the prevention of the use of narcotic drugs, as this infection is a growing danger for both drug users and public health in general. Breaking drug dependence must not be the only aim of services working with drug addicts, because this will exclude persons decisively disposed to the mode of life including the prolonged use of drugs from the sphere of their activity. Active INU having no contacts with organizations which must give them treatment and assistance find themselves in dangerous situations more often than INU maintaining contacts with such organizations. Penetration into such hidden group and its education must be the primary task. Propaganda plays a decisive role in this process, as the only way to penetrate into such group is to develop work in its territory, so that drug addicts, supplied with the necessary means could change their behavior in the desired direction. In the Russian Federation work on the project "Harm Reduction" has been carried out in 50 regions. This work has contributed to conducting teaching seminars, working out teaching programs, as well as to augmenting the interest among specialists of different professions to the problem of decreasing the spread of HIV infection. The importance of information distributed by the narcological service and the probability that very responsible persons take correct decisions on the basis of their understanding the situation have increased. The rating of public organization has risen.     

HIV infection in the penitentiaries of Ukraine

In connection with a sharp increase of the number of HIV-infected persons in the Ukraine the natural growth of the number of such persons in penitentiary institutions was registered, starting from 1995 (455 persons in 1995, 2,937 persons in 1996, 2,779 persons in 1997 and 173 persons during 5 months of 1998). 83% of HIV infection persons were drug addicts introducing drugs intravenously. In 1997 the strategy of decreasing the risk of infection in penitentiary institutions was worked out in collaboration with UNAIDS experts: repressive and isolation measures were replaced with measures aimed at the "decrease of harm". Special attention is given to circumstances aggravating the epidemic situation in HIV infection, and particularly at the sharp growth of morbidity in tuberculosis and syphilis (10.6 and 10.3 times respectively in 1997 in comparison with 1993). In addition, in 1997 the number of person having drug addiction was noted to increase 2.3 times in comparison with 1993. The necessity of taking constant information and educational measures aimed at decreasing the risk of the spread of HIV infection is emphasized.     

Development of HIV infection epidemic among intravenous drug users in the Sverdlovsky region

The Sverdlovsky region takes the fourth place among the 89 subjects of the Russian Federation by the number of registered cases of HIV infection. Drug addiction has reached an excessive scale in this region: according to the data of express evaluation carried out by the Regional Narcological Hospital and the Regional AIDS Center, not less than 7-8% of persons aged 15-30 years constantly use injection drugs. The large-scale epidemic of injection drug addiction has led to the rapid spread of HIV among addicts. The first penetration of HIV into this population took place in 1996 and, starting from the year 2000, rapid, development of the epidemic began, taking the character of an avalanche. The peak of new cases of HIV infection fell on 2001 (9,230 cases were registered). The concentrated stage of the epidemic development is observed in the region at present, the prevalence of HIV infection among drug addicts being 13.8%. Children born from HIV-infected drug addicted mothers now represent a new risk group due to great difficulties in the prophylaxis of the vertical virus transmission.     

The monitoring of the spread of drug abuse as an element in the epidemiological surveillance of socially significant infections

The necessity of monitoring the spread of drug addiction in the system of epidemiological surveillance on HIV infection and parenteral virus hepatitides is shown. The results of the epidemiological diagnostics of registered drug addiction are presented. The criteria for the assessment of the epidemiological effectiveness of epidemiological surveillance on drug addiction are determined. As revealed in this study, during the period of 1991-1998 morbidity in drug addiction rose 57-fold in Perm Province, while the number of HIV-infected persons increased 75-fold. Pronounced direct relationship between the number of drug addicts, as well as persons belonging to groups of high risk of developing drug addiction, and the dynamics of morbidity in HIV infection and parenteral virus hepatitides B and C was established.     

The HIV/AIDS epidemic and the trends in the behavior of people using injection narcotics (IDU)

The degree of risk of the spread of HIV infection among drug addicts in Zhitomir has been prognosticated. As revealed in this study, narcotic drugs are mostly introduced by individual dispensable syringes or by individual reusable syringes. But such factors as the repeated use of needles (47%), obtaining drug solution from different persons (49%), the injection of drugs under unsanitary conditions (62%), with-drawing drug solution into the syringe by some other person (32%), unavailability of the means of disinfection (64%), absence of knowledge and practice in disinfection (91%), the presence HIV-infected persons among IDU (41%), a low level of sanitary and hygienic culture (41%), lack of sexual restraint (93%), concubinage with IDU (44%), unemployment (66%), etc. have been found to increase the possibility of getting HIV infection twofold. The results of this sociological study have demonstrated new trends in the study of the behavior of IDU, necessary for the creation of the module for preventive work both in Zhitomir and the Zhitomir region.     

The characteristics of HIV infection during a sharp activation of the epidemic process in Rostov Province

A considerable growth in cases of HIV infection in Rostov Province was registered in 1996-1997. Number of men was 525, number of women--196 cases, were registered. The highest index of HIV infection was noted in group of tested by epidemiological evidence (4494,4 per 100,000 tested persons), which was 57.2 times higher than the average level for this region. The growth in the number of infected persons was due to the import of HIV from the territory of Ukraine and the subsequent spread of the virus among drug addicts introducing drugs by intravenous injection.     

The results of conducting a rapid assessment of the situation in relation to intravenous narcotic abuse in the city of Rostov-on-Don

The main aspects of the spread and intravenous use of drugs in the city, contributing to the transmission of HIV infection among users of intravenous drugs (UID) have been studied. Anonymous questionnaires were distributed among 61 UID; of these, 50 were males (82%) and 11 were females (18%), mainly at the age of 19-35 years. In addition, sociological study was carried out among 582 persons; 61% of them were under 18 years of age, 18% were aged 19-25 years, 13% were aged 26-35 years. The drug users regarded their individual risk of getting HIV infection as insignificant in 23% of cases, slight in 21% of cases, high in 15% of cases, and 15% believed they were at no risk. As shown by the results of the sociological study, 91% of the respondents believed that the problem of drug addiction was topical in the city. The analysis of data obtained from physicians treating drug addicts and from the Head Office of Public Health made it possible to calculate that the number of UID in the city was about 9,000-10,000 persons. Taking into account the results of the rapid evaluation of the situation, the development of the draft program of "diminishing the harm" of the intravenous use of drugs is now in progress.     

The results of sentinel epidemiological surveillance on the level of HIV prevalence among injection narcotic abusers in the city of Poltava

The sentinel epidemiological surveillance on the level of spread of HIV infection among injecting drug users in Poltava, taking part in the program of harm reduction, was carried out. The results of the surveillance revealed that the level of HIV infection among drug users was 37.8%, the level of HIV infection among females being higher than that among males. These data indicate that the level of HIV infection rises with the increase of age and the time of drug consumption. Still in the age group of 30 years and older and among drug addicts using drugs for 7 years and longer the lowest level of HIV infection was noted.     

The organization of the work to determine antibodies to the human immunodeficiency virus in the Republic of Byelarus

The study revealed that the method of mass screening for the detection of antibodies to HIV antigen, carried out in the Republic till 1993, proved to be economically and diagnostically unjustified. Starting from 1993, the work on the step-by-step reduction of groups to be tested for the presence of antibodies to HIV began. At the same time from 1997 the proportion of tested donors of blood, organs and tissues, as well as persons belonging to high risk groups, increased in comparison with 1993 (from 23.3% to 40% and from 5.3% to 21% respectively). Voluntary and anonymous testing for the presence of HIV infection was organized and legally introduced. In comparison with 1991, in 1997 the number of persons who voluntarily underwent testing increased 3.7 times. The period of transition from mass screening to selective one was noted to have no effect on the detection of HIV-infected persons. Since 1995 the method of "patrol" epidemiological surveillance was also used. 2,118 persons underwent testing, the results of screening were negative. During the period of 3 years the testing of 12,547 young people called up for military service revealed 28 seropositive persons in the region where an outbreak of HIV infection had been registered among addicts using drugs intravenously.     

The epidemic of human immunodeficiency virus-caused infection among users of psychotropic preparations in Russia

The development of the epidemic of HIV infection among the intravenous injecting users of psychotropic substances in Russia in 1994-1999 is described on the basis of the data provided by territorial centers for the prevention and control of AIDS. In addition, the results of the screening in individual groups of the population of Russia for antibodies to HIV, carried out at the period of 1994 to the first half of 1999, are presented. In 1999 a considerable rise in the number of newly detected cases of HIV infection, mainly among persons injecting psychotropic drugs intravenously for non-medical purposes, was noted. The conclusion was made that the spread of HIV among drug addicts led to its passage to other groups of the population, mainly by heterosexual transmission.     

The epidemic situation in relation to HIV infection in Ukraine (1987-1997)

The analysis of the dynamics of the epidemic process for 10 years made it possible to find out the presence of two separate epidemic waves of HIV infection. The first wave (1987-1994) was manifested as the slow type of the development of the epidemic, characterized mainly by sexual transmission. During this period 398 persons with HIV infection were detected, 24 persons were found to have AIDS; of these, 13 persons died. The second epidemic wave began in 1995 and was due to the spread of HIV among users of drugs introduced by injection. By the end of 1995 the number of HIV carriers was 34 times greater than that of 1994, reaching 1490 persons. In 1996-1997 this figure increased 8 times (annually). The number of AIDS patients rose to 420 persons. The most unfavorable regions with respect to HIV infection and AIDS morbidity were determined. The western regions of the Ukraine were noted to be in a more favorable situation in this respect with infection indices being lower more than 30 times. Up to 80% of all infected persons were found to be addicts introducing drugs intravenously. Growing morbidity in sexually transmitted disease, particularly in syphilis, contributed to the deterioration of the epidemiological situation. The conclusion was made on the necessity of introducing new prophylactic programs and expanding current ones. The signs of stabilization in Odessa and Nikolayev were observed; in these cities pilot programs aimed at the strategy of the "decrease of harm" have been introduced (in collaboration with UNAIDS) since 1996.     

Emergency measures to control the spread of diseases caused by the human immunodeficiency virus

Since the middle of 1996 the growth of HIV-infected persons and AIDS morbidity are registered in Russia. In 1997 4,300 new cases of HIV infection were registered, which exceeded 1.6 times the total number of cases for the period of 1987-1996. The highest morbidity rate was observed in the cities of the European part of Russia: Kaliningrad (west), Krasnodar and Rostov-on-Don (south), Nizhny Novgorod and Moscow (center). AIDS patients and HIV-infected persons were registered in 73 out of 89 regions of the country. 90% of HIV-infected persons were drug users in 1997. In 1992-1997 the number of drug addicts increased 3.5 fold and young women in 1987-1997, 6.5 fold. 71 HIV-infected children were registered were born from HIV-infected mothers at present time. The article deals with the main provisions of the federal laws aimed at the prevention of the spread of HIV infection in Russia and characterizes scientific research on AIDS. Evidence is presented that the early detection of HIV-infected persons, as well as rendering timely medical and social assistance to such persons, makes it possible to increase their mean survival time and check the spread of human immunodeficiency virus.     

The prevention of HIV infection and STDs among injection drug addicts in Ukraine

In 1996-1998 joint pilot Projects of the National Committee and the UNAIDS Program were carried out in 10 Ukrainian cities. The behavior determinants contributing to the spread of HIV infection, common for all regions under study, were determined. They were linked with the injections of narcotic drugs, sexual behavior and the level of knowledge on the infection. The effectiveness of the projects was due to the 80% coverage of those drug addicts who could not be reached by common narcotic drug services; to the use of individual syringes (increased from 43% to 95%); to a decrease in the sale of ready-made drugs in used syringes to 14%; to an increase in the index of the return of used syringes; to an increase in the proportion of persons constantly using condoms (58%); etc. Still the situation was found to give no grounds for optimism, and the conclusion was made that the strategy of "decreasing the harm" must become the policy and strategy of the public health system.     

Specific features of the HIV infection epidemic in Moscow

Retrospective analysis of the epidemic of HIV infection in Moscow allowed to mark out two periods: the first--from 1987 to 1993 and the second one--from 1994 to 2000. The characteristic feature of the first period of the epidemic was the sexual transmission of the agent mainly among homosexuals; the most affected group were persons aged 20-39 years and the number of AIDS patient decreased with a simultaneous growth in lethality. During the second stage of the HIV infection epidemic changes in the prevailing transmission routes of the agent occurred: injection drug addicts took the leading role. Changes in the ratio of HIV-infected men and women took place along with active involvement of persons aged 13-18 years into the epidemic process. The established changes in the epidemiological situation require corrections in the strategy and tactics of epidemic control and prophylactic measures.     

An analysis of the situation with injection narcotic usage in the city of Voronezh during the development of the HIV infection epidemic in Russia

The medico-demographic situation in Voronezh, characterized by a decrease in the birth rate, a rise in the mortality rate, the prevalence of pensioners (38%) in the structure of the population, is presented. The negative influence of the deterioration of socio-economic conditions on the social health of the population, especially on the situation with drug addiction, is pointed out. The extent of the misuse of narcotic and toxic substances among adolescents essentially increased. The rapid assessment of the situation with the intravenous use of drugs in Voronezh was carried out, following the WHO methodology. The conclusion was made concerning the necessity of complex sociological monitoring with a view to obtaining more reliable data on the number of drug addicts. The calculation of the supposed number of users in Voronezh among persons aged 15-30 years, made by three modules of assessment, revealed this number reached 61,374 persons, i.e. every fifth or sixth young person used some narcotic substances. The necessity of taking drastic measures on the primary prophylaxis of HIV infection among injecting drug users by creating conditions for the realization of the programs "Harm Reduction" and "Equal Helps Equal" which proved to be effective in other regions of the Russian Federation.     

HCV and HIV Infection among Heroin Addicts in Methadone Maintenance Treatment (MMT) and Not in MMT in Changsha and Wuhan,China

Objective

To compare HCV and HIV infection among heroin addicts in MMT and not in MMT in two large cities in central China.

Methods

A total of 541 heroin addicts were recruited from MMT clinics and voluntary detoxification centers in Changsha and Wuhan, China. Structured questionnaires collected data on their socio-demographics, clinical status, risk behaviors, and their knowledge of HIV. Their HIV serostatus and Hepatitis C virus (HCV) serostatus were determined by testing antibodies in blood serum.

Results

We observed a higher prevalence of HCV infection among MMT heroin addicts (82.3%) than that in the non-MMT group (50.6%). However, our findings indicated that the heroin addicts in MMT had less drug or sexual HIV/HCV risk behaviors and more knowledge about HIV than non-MMT addicts. The heroin addicts in MMT had a significantly higher percentage of individuals who always used condoms (44.9%) compared with patients in the non-MMT group (14.6%, p = 0.039), and they had more knowledge about HIV than non-MMT individuals (p<.001). The percentage of HIV-positive addicts in the MMT group (0.7%) and non-MMT group (0.8%) were almost same.

Conclusion

Our study indicated that the rate of HCV infection among heroin addicts among MMT or non-MMT settings in central China is very high. The non-MMT heroin addicts have higher risk of becoming infected with HCV in the future, while at present they have lower rates of HCV infection than MMT heroin addicts. Although rates of HIV infection among MMT and non-MMT heroin addicts are low now, they are all at great risk of becoming infected with HIV in the future, especially for non-MMT heroin addicts. We should use the MMT sites as a platform to improve the control of HCV and HIV infection in heroin addicts.     

The introduction of the concept of Harm Reduction in the city of Cherkassy

The introduction of the concept of Harm Reduction into the practical work of the narcological survive confidence relations with injecting drug users were established, which resulted in the possibility to carry out information and educational, as well as preventive work. In addition, there occurred changes in public opinion with respect to the problems of drug addiction (a drug addict was now regarded as a sick person) and AIDS (HIV infection was considered to be a problem, topical for wide strata of the population). The creation of a dedicated team comprising medical personnel, psychologists, representatives of the clergy, volunteers from drug addicts contributed to successes in this work. The work on the correction of negative manifestations, carried out by the organs of law protection, also contributed to the creation of balance between the strategy of Harm Reduction and the strategy of the reduction of need in narcotic drugs.