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.     

The clinico-epidemiological characteristics of HIV infection and AIDS in Ukraine

The summarized results of the observations of 449 hospitalized patients, aged mainly 18-37 years (40 patients with active AIDS, 43 patients with AIDS, other patients were HIV carriers and infected at the stage of lymphadenopathy). In most of the HIV-infected patients the infection process progressed in 3-5 years, which was manifested by associated candidiasis in 74.7% of cases. In AIDS patients opportunistic infections of viral etiology (herpes simplex, cytomegalovirus infection, etc.) prevailed. 14 patients were found to have tuberculosis. Clinico-epidemiological analysis made it possible to come to the conclusion that the specific features of HIV carriership and AIDS were greatly linked with different groups of risk to which the patients belonged. Thus, a shorter period of carriership, the prevalence of opportunistic viral infections were mostly characteristic of drug addicts.     

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.     

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.     

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.     

The epidemiological characteristics of HIV infection in Turkmenistan

In the presence of the low spread of HIV infection a sharp increase in sexually transmitted diseases is noted. Nevertheless, taking into account a rise in STD, the reality of the potential risk of the spread of HIV is emphasized. Thus, in 1996 morbidity is syphilis was found to grow 7.2 times in comparison with 1992, amounting to 37.5 cases per 100,000 of the population; morbidity in gonorrhea amounted to 32.4 cases per 100,000 of the population with the proportion coming to medical institutions not exceeding 30%. A high proportion of hepatitis B virus carriers was also established (from 15% to 30% of healthy persons), while morbidity in virus hepatitides rose twofold for the period of 1994-1995. During recent years the service for the prophylaxis of AIDS was noted to considerably decrease measures on mass screening. At the same time the article attracts attention to the necessity of increasing the work on the dissemination of information and education on HIV/AIDS drug among addicts, prostitutes and homosexuals. The Draft National Program of the Prophylaxis of HIV infection and STD for 1998-2002 has been worked out. Great importance of methodological and financial assistance rendered since 1994 by international organizations, including WHO, UNFPA, etc., have been emphasized.     

The role of interleukin-21 in HIV infection

Interleukin (IL)-21 is one of a group of cytokines including IL-2, IL-4, IL-7, IL-9 and IL-15 whose receptor complexes share the common γ chain (γ(c)). Secretion of IL-21 is restricted mainly to T follicular helper (TFH) CD4 T cell subset with contributions from Th17, natural killer (NK) T cells, but the effects of IL-21 are pleiotropic, owing to the broad cellular distribution of the IL-21 receptor. The role of IL-21 in sustaining and regulating T cell, B cell and NK cell responses during chronic viral infections has recently come into focus. This chapter reviews current knowledge about the biology of IL-21 in the context of HIV infection.     

Cost-effectiveness of pooled nucleic acid amplification testing for acute HIV infection after third-generation HIV antibody screening and rapid testing in the United States: a comparison of three public health settings

Background

Detection of acute HIV infection (AHI) with pooled nucleic acid amplification testing (NAAT) following HIV testing is feasible. However, cost-effectiveness analyses to guide policy around AHI screening are lacking; particularly after more sensitive third-generation antibody screening and rapid testing.

Methods and Findings

We conducted a cost-effectiveness analysis of pooled NAAT screening that assessed the prevention benefits of identification and notification of persons with AHI and cases averted compared with repeat antibody testing at different intervals. Effectiveness data were derived from a Centers for Disease Control and Prevention AHI study conducted in three settings: municipal sexually transmitted disease (STD) clinics, a community clinic serving a population of men who have sex with men, and HIV counseling and testing sites. Our analysis included a micro-costing study of NAAT and a mathematical model of HIV transmission. Cost-effectiveness ratios are reported as costs per quality-adjusted life year (QALY) gained in US dollars from the societal perspective. Sensitivity analyses were conducted on key variables, including AHI positivity rates, antibody testing frequency, symptomatic detection of AHI, and costs. Pooled NAAT for AHI screening following annual antibody testing had cost-effectiveness ratios exceeding US$200,000 per QALY gained for the municipal STD clinics and HIV counseling and testing sites and was cost saving for the community clinic. Cost-effectiveness ratios increased substantially if the antibody testing interval decreased to every 6 months and decreased to cost-saving if the testing interval increased to every 5 years. NAAT was cost saving in the community clinic in all situations. Results were particularly sensitive to AHI screening yield.

Conclusions

Pooled NAAT screening for AHI following negative third-generation antibody or rapid tests is not cost-effective at recommended antibody testing intervals for high-risk persons except in very high-incidence settings. Please see later in the article for the Editors'' Summary