Four years ago global leaders announced bold plans to wipe out Aids by 2030.
Huge global progress has been made in tackling an epidemic which has claimed over 35 million lives since the 1980s. But there’s one region in the world where infection rates from the human immunodeficiency virus (HIV) – the pathogen that causes Aids – have been quietly rising in recent years.
The HIV crisis in eastern Europe and central Asia – which gathered pace in the two decades following the disintegration of the Soviet Union in 1991 – has now reached epidemic proportions.
It prompted anti-Aids campaigners and activists to issue a stark warning at last month’s global Aids conference in Amsterdam that the region’s HIV crisis risks “exploding”.
Along with the Middle East and north Africa, it’s one of only two regions in the world where the rate of new infections is increasing year on year. According to new data from UNAIDS, the UN body tasked with helping end the epidemic, since 2000 the annual number of people in the region newly infected with HIV surged from 65,000 in 2000 to 130,000 in 2017.
Although sub-Saharan Africa – home to over two thirds of the 37 million people worldwide living with HIV – remains the centre of the epidemic, new infections in Africa, like much of the rest of the world, have been steadily falling since the late 1990s.
This is thanks to improvements in HIV prevention programmes, access to testing and treatment with antiretroviral drugs.
Vinay Saldanha, who heads the UNAIDS programme for the region, said: “We are at a time when countries and regions around the world are recording record progress on HIV – we’ve seen the epidemic stabilise in terms of the number of new HIV infections or at least come down significantly in many countries of the world. Unfortunately we are still not seeing this in eastern Europe and central Asia.”
According to UN figures, there are 1.4 million people in the region currently living with HIV.
An epidemic rooted in drug use
Although the first official case of HIV was detected in the region in 1987, many experts link the start of the epidemic to the end of communism.
While the fall of communism brought an end to decades of hardship, it also signalled an end to the security of a universal job for life while at the same time opening up the former Soviet Union’s borders to trade, travel – and to drugs such as heroin.
Along with the spiralling rates drug addiction came its associated problems – including HIV and Aids.
“The first cases [of HIV] were diagnosed among injecting drug users in 1995 and 1996. It was thought they were only a few but then really the epidemic exploded,” said Mr Saldanha.
As a consequence, today, 39 per cent of all new infections in the region are among the region’s injecting drug users – elsewhere in the world, just nine per cent of new infections are among this group.
Mr Saldanha says that sub-national trends in the region’s epidemic strongly show the influence of drug use in driving the HIV crisis.
Take Russia, the region’s largest country: within the country, the epidemic is heavily concentrated in a relatively small number of hotspots with 80 per cent of all diagnosed cases in the country occurring in just 20 of Russia’s 80 regions.
Moscow, St Petersburg and their surrounding areas, along the Volga river and parts of Siberia are among the places most affected.
“These are the most economically prosperous and industrially most developed cities and regions in Russia,” said Mr Saldanha. “You can almost follow the geography of HIV in Russia, in Ukraine and many other cities in eastern Europe and central Asia based on where there were big industrial urban centres, where the drugs followed the money and the HIV followed the drugs.”
In the Volga city of Tolyatti for instance, home of the Lada car factory, it is thought some 5 per cent of men are HIV positive – the highest rate in eastern Europe.
Few people are on treatment
One reason why the crisis in the former Soviet states continues to persist while much of the rest of the world makes progress is the region’s low rate of treatment with anti-retroviral drugs (ARVs).
Since the first (partly) effective ARV against HIV was approved in 1987, use of such drugs – which help prevent infected people from transmitting the virus to others – has become widespread around the world. In 2017, 21.7 million of the 37 million people with HIV (59 per cent) were receiving treatment – five and a half times more than a decade ago.
Rates of treatment coverage in eastern Europe and central Asia by contrast are the lowest in the world. Only 35 per cent of HIV-infected people are on the drugs they need due in part to financing gaps.
National and local harm reduction programmes – another key way to halt new HIV infections among drug users – have also been patchy, reaching only a fraction of the people in need.
“The response is still very slow and dragging behind the pace of the epidemic”, said Mr Saldanha. The fact that countries in the region are wealthier middle-income states has meant that international Aids-fighting bodies such as the Global Fund are more reluctant to fund drugs for them, he added.
Russia – the epicentre of the region’s epidemic
One country where the government has been particularly slow to respond – although things may be changing – is Russia, which is home to at least 1 million (or 70 per cent0 of the region’s 1.4 million HIV cases.
“The problem is particularly acute in Russia because the population is so large, the country is so large and the size of the estimated epidemic is so large”, said Mr Saldanha.
Over the last three decades Russia’s share of new HIV cases in the region has climbed steadily from 4 per cent of new infections in 1990 to 77 per cent in 2017.
But Russia’s infection numbers are not only remarkable within a regional context. In 2017 the country had the fourth highest number of new HIV infections in the world – with only South Africa, Nigeria and Mozambique seeing more new diagnoses.
According to experts and campaigners, a lack of political commitment, a socially conservative approach to sexual and reproductive health, draconian anti-drug laws and neglectful funding of the domestic HIV and Aids response has allowed the disease to flourish.
Professor Vadim Pokrovsky, Russia’s foremost HIV expert and director of the Federal AIDS Center in Moscow says that this has led to a reluctance to adopt the methods proven to reduce HIV transmission.
“Ten years ago many Russian politicians who wanted to look like Orthodox Christians used demagogy similar to Roman Catholicism which denies sexual education, condom use, etc. Some of them declared that condom use would reduce the Russian population and it has not been easy to return the word ‘condom’ to mass media use,” said Prof Pokrovsky.
He says that similar attitudes have also blocked effective treatment avenues for injecting drug users. Methadone and other kinds of opioid substitution therapy recommended by the World Health Organization are illegal in Russia (as in Uzbekistan and Turkmenistan).
“You see a similar situation with substitution therapy,” says Prof Pokrovsky. “Many politicians declare that it’s wrong to replace one narcotic drug with another but it’s necessary to cure drug addiction.”
Other so-called harm reduction methods proven to help prevent HIV transmission such as needle-exchange programmes, while not illegal, are poorly funded.
Meanwhile, the law requires foreign-funded NGOs who conduct ‘political activity’ to identify themselves as a ‘foreign agent’ hampering the work of many community HIV-organisations.
A changing epidemic?
While the bulk of new infections continue to be driven by needle sharing, experts are increasingly worried that the dynamics of the epidemic are changing as the virus is increasingly spilling over from drug users into other parts of the population. Almost half of new cases in Russia are now from heterosexual contact.
“For at least the last 10 years the almost exclusive focus was on injecting drug users or people who inject drugs and rightly so as they accounted for 60 to 70 per cent of new HIV infections. Now they account for about 30 to 40 per cent of new HIV infections,” said Mr Saldanha.
“That’s not to say the region does not have an epidemic that’s concentrated among key populations. But it’s not only the injecting drug users. It’s the injecting drug users and their partners, it’s the sex workers and their clients, it’s the men who have sex with men and in many cases, even their heterosexual partners as many of these men are not openly gay,” he said.
Faced with an epidemic at risk of spilling over into more of the population, the government seems to be taking the problem more seriously.
“There’s perhaps more government action on HIV in Russia in the last three years than we have seen in the last 30 years since the first case of HIV was diagnosed in Moscow in 1987”, said Mr Saldanha.
Last year, the Kremlin adopted its first ever state strategy on the disease, which on paper at least, commits the country to a 75 per cent reduction in new cases by 2020. Public funding to tackle the epidemic has also been increased from 18 billion roubles (£211 million) to 22 billion roubles (£258 million).
Prof Pokrovsky is optimistic that criticism of the government’s attitude to tackling the disease by experts such as himself are finally paying off.
But he feels that the current strategy still does not go far enough.
“The [Health] Ministry is completely focused on the “test and treat” strategy but it’s also necessary to use preventive programs such as sexual education, training of sex workers and drug users, syringe exchanges, substitution therapy and PrEP [a daily medicine taken preventatively to lower the risk of HIV infection among HIV-negative people],” he said.
Mr Saldanha who shares Prof Prokovsky’s caution says that things could well appear to get worse before they get better.
“Unfortunately I think the numbers are going to keep going up only because there’s such a push on the so called first 90,” said Mr Saldanha, referring to the UN 90-90-90 target to catch 90 per cent of infections, treat 90 per cent of them, and achieve undetectable viral loads in 90 per cent of the treated cases.
“HIV is one of these bizarre areas where the more you look for it the more you find it,” he said.