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Date Posted: 11:57:24 05/16/02 Thu
Author: Anonymous
Subject: Letter from Moscow

http://www.medscape.com/viewarticle/431132_print

AIDS Bulletin
Letter From Moscow

Jay F. Dobkin, MD

Infect Med 19(3):104-105, 2002. � 2002 Cliggott Publishing, Division of SCP Communications
Introduction
Writing this column, I find myself at the epicenter of the world's AIDS epidemic, at least in a statistical sense. According to the December 1 update of the Joint United Nations Programme on HIV/ AIDS, Eastern Europe and the former Soviet Union represent the region with the fastest growth in the number of new HIV infections for the second year running. An estimated 250,000 new cases in 2001 brings the regional cumulative total to 1 million. Projections of millions of cases in the next decades have been put forward; and yet, unlike in sub-Saharan Africa, the inevitability of a massive epidemic here is not yet sealed.

Fueled by injection drug use, HIV has spread widely across this vast area, and there is an enormous high-risk pool of drug users -- not to mention their sex partners, who are exposed as well. Raging epidemics of sexually transmitted diseases (STDs) add to the risk. And yet, more than some other areas at comparable early stages, the former Soviet countries may be able to blunt the growth of this plague. With the support of the Gold Foundation at Columbia University, I am participating in a joint project of the Soros Foundation's Open Society Institute and Doctors of the World to assess measures to stop the spread of HIV among drug users in this region and to evaluate the potential for augmentation of HIV disease treatment as an additional prevention strategy. Here are some preliminary observations.

As much as any other epidemic disease, the spread of HIV infection reflects socioeconomic conditions, including war, poverty, and the subjugation of women. Ten years after the disintegration of the Soviet Union, there is reason to think the worst of this is over. The social disruption that characterized the early changes seems to have stabilized; food shortages have abated; and some elements of the new economy, especially in the oil sector, are showing strong growth. Also, the massive layoffs attending the collapse of the planned economy are mostly over. Yet the opening of society to travel and the loosening of authoritarian social controls have contributed to the growth of drug use and STDs.

Controlling Disease Spread
Aggressive efforts have been started to control HIV spread all across the region, with the support of government as well as local and international nongovernmental organizations. The focus of our visit is the network of needle- and syringe-exchange harm-reduction sites supported by the Soros Foundation. Compared with the United States, where needle exchange has remained highly controversial and constrained by local opposition and restrictions on government support (federal funding for needles and syringes is still banned), the programs here have gotten off the ground quickly, though not without obstacles. A major limitation is police interference, often for corrupt reasons, in spite of official approval. Drug users are identified at the exchange sites and then are shaken down for bribes, or end-of-the-month sweeps are made to inflate arrest statistics. We also encountered residents who resented the attention given to addicts and complained that they could not get syringes for their own medical needs.

Additional prevention activities have targeted commercial sex workers -- a growing and problematic group, given their high rate of injection drug use and STDs. Aggressive street outreach with distribution of needles, condoms, alcohol swabs, prevention literature, and medical referral slips was evident at one site where the staff uses an old ambulance to find prostitutes soliciting truckers on the main Moscow-St Petersburg highway. It is often hard to assess the efficacy of HIV prevention programs, especially those targeted at drug users. Yet in 2 cities where large HIV outbreaks began in 1997 and prevention activities were promptly launched, the incidence of new cases appears to have stabilized or declined slightly.

Deficiencies in Treatment
One area in which there is a gaping deficiency is treatment, both of HIV infection and of HIV-related complications. There are several causes, including unfamiliarity with the diseases and the disinclination of some physicians to care for HIV-infected drug users, but most prominent is the limitation of resources, especially drugs. The Soviet medical system, still largely intact, emphasized a highly specialized, hospital-oriented approach to care. Cost of outpatient medications, for instance, is nearly always the patient's responsibility. Routine use of inexpensive drugs, such as trimethoprim-sulfamethoxazole, is possible in some settings, but not in others. But the generally impoverished state of health care makes the provision of antiretrovirals extremely difficult.

The question posed by our project is whether offering comprehensive care, including antiretrovirals, could augment prevention efforts by drawing in more high-risk clients, motivating identification of contacts, and generally increasing the credibility of prevention efforts. Since HIV spread is still at a relatively early stage, this might be a cost-effective strategy if it ultimately helped limit the potentially enormous size of the epidemic. The obstacles to this deceptively simple strategy are enormous, though. There is little interest among the international AIDS donor community in paying for treatment as opposed to more traditional prevention strategies, and treatment of HIV-infected drug users is not seen as an important priority in the struggling health care systems of the former Soviet countries (although this could change as HIV disease progresses and large numbers of sick patients fill hospital beds). At a time when attention has focused on more equitable access to AIDS treatment in resource-poor countries, the situation in the former Soviet Union presents many of the same challenges as in sub-Saharan Africa, but also several unique issues and opportunities.

Dr Dobkin is associate professor of clinical medicine, Columbia University College of Physicians and Surgeons, and medical director, Presbyterian Hospital AIDS Center, New York.

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