In the authoritative medical journal The Lancet on July 19, 2016, a large-scale study of the development of the HIV pandemic was published. The work prepared in the framework of the international project “ The global burden of disease” (Global Burden of Disease, GBD), covers the period from 1980 to 2015 and describes the main trends in the rate of infection, the number of infected, mortality and treatment success. The authors of the study believe that over the past decade, significant international investment in AIDS programs and the development of effective drugs for antiretroviral therapy has stabilized the rate of infection (it fluctuates between 2.5-2.6 million cases annually) and reduced mortality (in 2015 – 1.2 million deaths worldwide). But the total number of HIV-infected people continues to grow steadily. Today, about 39 million people live with the immunodeficiency virus worldwide.
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According to the study, at the end of 2015 Russia is not among the leaders in terms of the total number of HIV-infected people (610 thousand, according to the study), although this indicator is comparable to all Western European countries together (651 thousand). But in terms of the number of newly infected, this is the European record holder: 57 thousand infected per year, four times more than in all countries of Western Europe combined, as many times more than in neighboring Ukraine, more than two times more than in USA. Below Russia in this indicator were only India (where the number of new infections is higher, 196 thousand, but far from proportional to the difference in population) and the countries of subequatorial Africa: South Africa, Zimbabwe, Nigeria, Kenya, Mozambique, Tanzania, Uganda and Zambia. Of course, the incidence can be considered in relation to the population of the country,
“Compared, for example, with subequatorial Africa, in Russia the number of patients relative to the population is not so large,” says Bulat Idrisov, (Bashkir State University / Boston University Medical Center), one of the co-authors of the study. – But the growth rate of newly infected is catastrophic – more than in any other country in Europe. In terms of the rate of growth of new infections, we are in the same group as countries such as Pakistan, Cambodia and Kenya.
But there is another indicator by which the Russian Federation cannot even boast of being compared with African countries like Nigeria. This is the percentage of people living with HIV who have access to antiretroviral therapy (ART). According to the GBD study, in Russia there are only 14 percent of them. Medical coverage is worse in only five countries: Afghanistan, Pakistan, Madagascar, Comoros, Somalia and South Sudan. In the DPRK, 19 percent of HIV carriers receive ART, in Ukraine – 28 percent, in the USA – 70 percent. The world average is about 40 percent.
“The data on antiretroviral therapy in the study is impressive,” says Anya Sarang, president of the Andrey Rylkov Foundation for Health Protection and Social Justice . “But this was to be expected: more than half of the Russians living with HIV and the cases of new infections are people who inject drugs. But there is a complete lack of systematic drug addiction treatment in the country, so it is difficult for these people to both adhere to the treatment regimen and start it.
According to the Russian Federal Center for Prevention and Control of AIDS, about 57 percent of newly diagnosed HIV infections in 2014 were the result of drug use with non-sterile instruments.
Sarang explains that infection through syringes is the fastest way to spread the infection. Vertical transmission, i.e. transmission of the virus from mother to child, is relatively effectively controlled, infection through sexual intercourse, despite the curtailment of safe sex programs, contributes less simply because infection is less likely to occur. “In my opinion, the lack of drug addiction treatment programs is responsible for 80 percent of the horrendous statistics in the study,” says Sarang.
Bulat Idrisov explains that in other former Soviet republics, even those in more difficult economic situations than Russia, better HIV statistics may be the result of effective drug treatment programs.
There is a point of concentration of the epidemic – these are people who use drugs intravenously. In order to prevent transmission, there are several effective and cheap methods often referred to as “harm reduction” – in particular, the distribution of injecting equipment (needles and syringes so that people suffering from addiction do not share the same needle) and drugs from the opioid receptor agonist class, such as methadone. There is none of this in Russia, but there is in Georgia, and we probably see the reflection of this difference in our sad numbers, behind which are the death and torment of tens of thousands of people and their loved ones,” he explains.
Anya Sarang assures that it is the lack of substitution therapy for drug addiction in Russia that is responsible for the extremely low coverage of HIV-infected people with antiretroviral therapy.
Around the world, ART is provided in programs for drug dependent people, usually as part of a substitution therapy program with methadone or buprenarphine. People come every day and, along with methadone or another synthetic opioid, receive drugs for the treatment of tuberculosis, HIV therapy. The system ensures that people take their pills daily.
Sarang talks about a study she did for WHO on barriers to accessing ART in Russia:
It turned out that one of the significant problems is that doctors are afraid to prescribe ART to drug addicts, because the risk of failure is high. It often happens that a patient comes for therapy, they are told: first solve your drug problem. But in Russia it is impossible to solve the drug problem, since there is no substitution therapy, no rehabilitation programs.
The statistics published in The Lancet raise doubts among some Russian experts. For example, the official data collected by the Center for Prevention and Control of AIDS look even worse than those presented in the GBD study: more than a million infected (instead of 610 thousand in GBD), 93 thousand new HIV cases in 2015 (in the study – 57 thousand), 27 thousand dead (in the study -18 thousand). Bulat Idrisov explains that there is no one-size-fits-all way to collect up-to-date information on HIV status worldwide: “Therefore, a variety of statistical methods are used. They are based on official statistics at the national and regional levels, as well as data obtained from representative population samples. There are usually several such sources for each country, and their data are combined using statistical models.
Vadim Pokrovsky, head of the Federal Center for the Prevention and Control of AIDS , is sure that the statistics given in the GBD study are underestimated not only for Russia, but also for other countries. “Indeed, the main problem in Russia is the trend towards an increase in the number of new cases,” Pokrovsky said. “Although on a global scale, this epidemic is not yet comparable to the countries of Africa. Now the situation in our country is most comparable to the situation in the United States, where the total number of infected people is approximately the same as in Russia, however, with twice the population. But with the developing countries of the world, at least with African countries, of course, the comparison will be more than incorrect.
Pokrovsky claims that a third of HIV-infected people in Russia have access to antiretroviral therapy, and not 14 percent, as in the study. He is sure that this is not enough: “We must focus not on the worst, but on the best results, and of course, we must focus on Canada, Australia, the United Kingdom, where such access can reach one hundred percent.”
Vadim Pokrovsky agrees that one of the factors behind low access to ART is the lack of substitution therapy for drug addicts. “Of course, here we need to focus on world experience,” he says, “and it shows that harm reduction programs, among which there are substitution therapy programs, are the most effective here. It is debatable whether these programs are effective in terms of drug addiction recovery, but now it is more important for us to stop the HIV epidemic, and then we will treat drug users for drug addiction.
However, Pokrovsky is sure that in order to effectively fight AIDS, it is necessary first of all to increase funding for relevant programs: “The United States spends about $30 billion on the fight against HIV infection, and Russia about 20 billion rubles. Therefore, of course, the response to the epidemic so far in Russia is much weaker.”
Pokrovsky considers the situation in Russia a national catastrophe and, despite the fact that the AIDS problem has been discussed in the last year at the level of the government health commission, he does not see any significant steps being taken. “Let’s hope that the time has not yet come, the Russians are harnessing slowly,” Pokrovsky concludes optimistically.
An article with the results of the study (in English) is available online at The Lancet.
