Date: Fri, 15 Aug 2008
From: "Murray Feshbach" <Murray.Feshbach@wilsoncenter.org>
Subject: HIV in Russia
WHAT’S IN A NUMBER?
A NEW PROJECTION BY POKROVSKIY’S CENTER FOR HIV PREVENTION AND TREATMENT AND
SOME CONSEQUENCES FOR RUSSIA
By Murray Feshbach, Ph.D.
Woodrow Wilson International Center for Scholars
13 August 2008
(murray.feshbach@wilsoncenter.org)
Buried deep in several documents released in 2007 on the website of the Federal Center for the Prevention and Treatment of HIV, headed by Dr. Vadim Pokrovskiy, is an astonishing projection of the number of adults who will require anti-retroviral therapy (ART) by the end of 2010. If this new projection for two-and-half years from now is approximately correct, given past experience many individuals likely will not receive the appropriate treatment and many will die or be invalided. According to information found in the fifth volume of the 6 volumes issued in 2007, the “largest increase in deaths in AIDS is expected to occur in Russia during the period 2009 to 2015.” This, in turn, will have serious implications for the health of the population, for the economy, for the military, and for the society of Russia.
Last month, Dr. Peter Piot, the head of UNAIDS, was quoted in Agence France Press on his evaluation of the situation in Russia and Eastern Europe. At a press conference on July 29, 2008 marking the latest annual report of his organization Piot noted that: “I am still very pessimistic about what is going on in Russia and Eastern Europe. That is the region of the world where there is the least progress.” If the number one problem is the high share of Injection drug users in Russia (and Ukraine) then the rejection of substitution therapy (with methadone) will inhibit any progress. Thus, “As long as that’s illegal there is no way we can bring this epidemic under control.” And further, “That is not a matter of money. That’s a matter of political leadership and changing the policy.” With the recent rejection by Dr. Gennadiy Onishchenko, the Chief Public Health Physician, of this therapeutic approach, Piot’s words are sufficient to be even more pessimistic. When combined with the evidence available on the trends of not only HIV/AIDS but also of TB in its various manifestations, and the increases in incidence and death in the Russian Federation, the prospect for Russia appears forbidding.
It was only in 2006 that a serious effort was begun to give ART treatment to more than just a few thousand persons. According to the Pokrovskiy Center’s documents, only made available in April of this year, 2008, in 2004 and 2005, respectively, antiretroviral therapy (ART) was given to 2,773 and 4,847 persons, (or according to another source, much higher in 2005 at 7,015) were provided with HAART (Highly Active Anti-Retroviral Therapy, alternatively abbreviated as ART); this is noted to be only 20 percent of those needing the treatment at the time. In 2006, the number more than doubled to 14,433 (or 14,681, according to the Federal AIDS Center); still only 27.5 percent of estimated demand. Interruption of treatment was recorded for almost 10 percent in both 2006 and 2007 (1,309 and 2,990, respectively). More than twice as many defaulted for one reason or another in 2007, possibly leading to a drug-resistant form of HIV. In 2007, the provision of ART increased to 30,526 persons from domestic funding sources, and another 7,000 to 8,000 from foreign aid such as the Global Fund for Tuberculosis, AIDS, and Malaria, and USAID as well. Supposedly, by the end of this year, 2008, some 40,000 will receive treatment. At the June 2008 UN conference for Global Leaders in New York, Onishchenko, referred to provision of ART at that point in time to more than 35,000 persons.
Since Russian experience is that a person who is infected with HIV will “convert” to full-blown AIDS in 8 to 10 years after becoming HIV-positive, and that the peak year for new cases in Russia was 2001, then it is no surprise that in 2009, many more persons are projected to be in need of this medication, i.e., 60,000. However, by the end of 2010, one year later, if the Pokrovskiy Center’s projection is reasonably correct, the number needing antiretroviral therapy will jump by almost eight times, to 467,000. This demand estimate is ALMOST 40,000 MORE THAN THE OFFICIAL CUMULATIVE NUMBER of 428,154 ON 31 MAY 2008. Even if we arbitrarily reduce the 2010 projected figure by one-third, to 312,000, it is still quintuple the level of antiretroviral medication needs projected for 2009.
It likely will be very difficult to achieve this level of treatment even if prices for anti-retroviral preparations declines further, even if it is fully distributed throughout Russia, even if projected increases in money is actually made available and utilized rather than diverted to other non-designated purposes, and at least as important, the number needing treatment is more than the current officially registered number of all cases of HIV and AIDS. Or, as is likely the more correct figure of HIV prevalence in Russia, is the middle figure of the recalculation made several years ago by UNAIDS. At that time, 940,000 cases of HIV/AIDS in Russia [was estimated. If about 1 million is correct currently, then the population needing ART will be one-half of the more recent estimate by UNAIDS. It is also important to keep in mind that the number of new cases, as officially recorded, has increased in the last four years from 2004 to date, including some 500 to 1,000 foreign citizens. It was 39,998 (39,652 Russians) in 2006 and 43,997 (42,770 Russians) in 2007, respectively. A smaller annual total may be recorded this year in the Russian Federation if the half-year figure of 13,109 is reflective of the full scope and coverage of all reporting AIDS Centers (usually Moscow city and outlying areas are late in reporting to the Federal AIDS Center). There is also a question of whether or not the half-year figure includes cases among the military and prisons. Of the half-year 2008 estimate, antiretroviral treatment is indicated for 5,559 (or about 42 percent) of the reported number of new cases.
The major jump in persons needing antiretroviral therapy (of 467,000), might possibly be explained by new and frequent references by various medical authorities to initiate ART when the CD4 T-cell count per cubic millimeter of blood is no less than 350 (rather than the past 200 level) or even to begin at 500. If so, the more than 450,000 figure, could be a first attempt by the Federal AIDS Center to determine the new, much earlier need to give ART before the CD4 level declines further. As pf mpw. the responsible Russian authorities have never published such a CD4 frequency distribution for those who are PLWHA (Persons Living With HIV or AIDS); I asked Pokrovskiy several years ago about this distribution. So far, however, regrettably and only rarely are local area frequency distributions of CD4 counts found in the medical literature. These data sets are vital for the Russian medical authorities to analyze in order to avoid late stage initiation of antiretroviral therapy, i.e., at 200 cells/mm3. If started at 350, the patient should be able to avoid such complications as peripheral neuropathy, anemia or kidney disease, according to an article in the Journal of AIDS, in January 2008. However, another source indicates that simultaneous TB and HIV treatment lowers the full efficacy of HIV treatment. Further study is called for to determine which is correct. +
Given that, as noted previously, the single year peak of new cases of HIV was in 2001, 87,671 new cases, the “8 to 10” year’s conversion to full-blown AIDS is upon them and thus the need is also imminent. If the treatment is not provided, then many will die. Improvements in supply have taken place, but insufficiently so to preclude interruptions and even fraudulent medications being given to patients. Putin has recently called for Russian-produced medications to meet “world standards.”
HIV-positive pregnant women are almost totally provided with ART (about 90 percent). The HIV-positive population of the penitentiary system currently are provided with proper treatment of more than two-thirds (68.3 percent of 5,476 at the end of 2007), which is double the rate of 2006 when it was only one-third (32%of the 3,784 requiring ART), an improvement despite an almost 50 percent increase in the number if such inmates requiring ART. I have not found any information on the number of persons in the Armed forces requiring antiretroviral therapy, nor any very recent number of those with HIV. Enlisted personnel are discharged immediately upon being diagnosed with HIV or AIds; officers are not discharged but treated at military hospitals. Their number is unknown. Some Commercial Sex Workers (CSWs), some Men who Have Sex with Men (MSMs), and other groups are provided with ART, but the numbers reportedly are small. Various regional surveys also show that HIV infection rates among these groups vary markedly. For example, for CSWs, the proportion with HIV in in Moscow City it was 15 percent, in St. Petersburg, 48 percent and in Tolyatti, 62 percent Moreover, they are very difficult to enumerate, so they may be underexamined and therefore undercounted.
The Joint Stop TB Partnership of WHO, UNAIDS, the World Bank and the Global Fund, are more and more strongly warning world leaders about the danger from the TB and HIV danger. During the UN General Assembly’s HIV/TB Global Leader’s Forum, held in June of 2008, much was made of the fact that the TB/HIV combination requires strong and consistent funding, prevention and treatment now and not in some amorphous future time.
While other countries have higher prevalence rates of HIV/AIDS such as in Sub-Saharan Africa, the Russian Federation is facing both a high burden of tuberculosis and a continuing increase in HIV despite recent efforts. A recent recalculation upward by 43 percent was found necessary in the number of new cases of HIV/AIDS in the United States, that is, from 39,400 to 56,300 cases in 2006. Simultaneously, by 2007, there were less than 14,000 new cases of TB per year for our 303-plus million population. The Russians record (officially) some 120,000 new cases (or by EURO TB estimates, including categories not counted in Russian statistics, over 150,000 cases in 2006) for their 142 million population. TB deaths in Russia are 24,000; in the United States, deaths from TB amount to around 650 per year!
Confounding the issue of tuberculosis incidence in all the countries of the world are the reports of growing multi-drug resistant (MDRTB) and extensively drug resistant (XDRTB) tuberculosis, which in turn leave the patient with a weakened immune response to possible secondary infections such as HIV.
WHO Stop TB reports show that in 2005, Russia was the only one in Europe of the 22 countries that was a TB “High Burden Country,” and ranked 12th among the 22 listed. Estimates and projections for MDRTB and XDRTB show Russia as the highest among all 25 Priority Countries for MDRTB in 2007 and second in 2008; for XDRTB, Russia ranked highest in both 2007 and 2008. While these figures very likely represent rough estimates and projections for 2008, it is quite indicative of the potential for HIV co-infection and mortality projections. The latest WHO Report No. 4 on “Anti-Tuberculosis Drug Resistance in the World,” clearly emphasizes the negative Russian situation.
Two-thirds of all persons dying in an HIV-positive status in Russia are found to be simultaneously co-infected with tuberculosis; the share of such pathology findings has increased from 60.0 to 66.5 percents in the last two years (2006 and 2007). While not all secondary infections are as life threatening as tuberculosis and HIV, their numbers apparently are increasing markedly. Results of newly implemented reporting forms provide previously uncollected information of secondary infections and TB/HIV, in particular. The annual numbers almost doubled.
According to the Federal AIDS Center, the cumulative numbers of all co-infections were 25,176 and 46,513 in 2005 and 2006, respectively. Of these, TB co-infections with HIV not quite doubled from 3,777 to 5,571 new cases in these 2 years, and very likely will continue to increase.
At an international conference recently held in Moscow (May of 2008), Dr. Olga Frolova, Director of a Ministry of Health Anti-TB Assistance to HIV-Positive Persons Institute, provided some clarification of the estimates of TB/HIV figures for Russia in the period 2005 to 2007. Regardless of which of the 3 definitions one chooses, all show significant increases in their number. Utilizing Russian Ministry of Health figures for the registered cumulative number of co-infections of active tuberculosis and HIV infection, it is seen that the numbers had doubled in the 3 years for which data are provided. The increase from 6,850 cases in 2005 to 14,293 in 2007. The increase in new incidence doubled as well, from 1,926 in 2005 to 3,907 in 2006 and 5,985 in 2007. Since many die shortly after the co infections occur, then the cumulative numbers are less than the sum of the new cases, year to year, and thus reflect the mortality impact among this population. In the materials provided to the attendees at the June 2008 Global Leaders’ Forum, the mortality potential was underscored, as follows:
“Because HIV weakens the immune system people living with HIV are up to 50 times more likely to develop TB disease over their lifetimes than people who are HIV negative. Without proper treatment with anti-TB drugs, the majority of people living with HIV die within two to three months of becoming sick with TB.”
A protocol signed by Onishchenko on March 14th, of 2008, noted that TB/HIV deaths in 2006 amounted to 1,625 occurrences, which in turn, was 41.3 percent more than in 2005. From this we can derive that 1,150 TB/HIV deaths occurred in 2005. As TB/HIV continues to spread, then the number of deaths will amount to a larger number that will also impact the population’s health status and associated problems that ensue.
In addition to the direct links of these illnesses to be a likely cause of death, it is also necessary to add the potential for serious increases in mortality from Hepatitis C (HepC) alone or in combination with HIV. The typical pattern is for HepC to take 10-15 years to gestate from its initial onset. Until recently some 70 to 80 percent of all HIV cases in Russia were found among Injection Drug Users (IDUs), and that 70 to 80 percent of them were infected with HepC. However, because of the currently very expensive and relatively unsuccessful protocols for the treatment of these persons (with HepC, or HCV), many will die also from the combination in the next 5 years or so, using the peak 2001 new incidence year as the benchmark reference year.
If so it will add to the difficulty of the Russian government to stem the decline in the country’s population as a whole regardless of (finally) paying more attention to the mortality side of the population growth equation. Moreover, those who die will be young. In contrast to the western pattern of HIV/AIDS illness where 70 percent or more are over 30 years of age, in Russia, the infected group is mostly male (but now being feminized due to heterosexual transmission increasing markedly), and the males are overwhelmingly between the ages of 15 to 29 years of age, inclusively. And if the past is prologue to the time of death even attenuated by the use of ART by some 13 years, they will die at a young age. This affects the labor supply, or if not the supply per se, then at least their productivity on the job while undergoing treatment.
Given that the Ministry of Labor and demographers have warned that there will be a shortage of 1 million persons per year, or of some 22 million workers by 2020, the urgency of dealing with this problem is manifestly clear. In a paper on Russian military and its population and health constraints I prepared for the Swedish Defense Commission in October of 2007, the demographic echo of past major declines of 50 percent in the numbers of births of males (and females, as well, of course), will lead to a sharp reduction in the absolute and relative number of males available for the draft or the volunteer military. Moreover, the health problems of the youth affects their potential for being conscripted, and if so, they are not chosen for assignment to combat arms components of the military while on active duty. To compensate for these demographic and health impacts, more effort is being made to recruit females for the military, including for combat training.
Legal migrants can compensate for some of the net decreases from among the population born in or dying prematurely in the country. However, the Government’s migration policy is constantly undergoing revision and the situation of migrants is confused. Many cases of HIV (1,696), TB (3,360), sexually transmitted infections (5,188), and other infectious diseases (2,665) are found among the labor migrant population, and add to the complexity of these problems for Russia.
Lastly, and far from last in importance, the economic burden even in newly wealthy Russia will be very significant. Not only in foregone output per worker of seriously ill or disabled (and of course, deceased), individuals, but also the financing of attempts to prevent, care for and acquire medical supplies for this growing segment of the population, but also for the poor condition of the infrastructure. A clear example of how poor it is in TB facilities was made by Onishchenko in late 2007, and summarized by Interfax in January of 2008, to the effect that:
“only 9 percent of TB hospitals meet current hygienic standards, 60 percent need capital repairs, 21 percent lack either hot or cold running water, and 11 percent lack a sewage system…42 percent of hospitals have inadequate medical equipment and … 20 percent have a shortage of TB drugs.”
With these potentially high, necessary and very important demands for funding, and others not even referred to by Onishchenko such as high-level laboratories throughout the country that the Stop TB organization of WHO is making a major effort to upgrade, the costs will be a formidable claimant on the budget that they are only beginning to appreciate. Minister of Finance Aleksey Kudrin has at times expressed his concern about the various fiscal requirements of the so-called National Projects, including for Health. His worries over inflationary tendencies add to his trepidation. If this will be the policy adopted, then the real needs of the TB epidemic and other urgent health funding for HIV/AIDS , hepatitis, heart and cancer incidence, as well as reproductive and child health issues, among others, can be expected to be constrained given the multiplicity of claims on the expanded Federal and local budgets and foreign aid.
Much more is being done to cope, much more is needed, and the needs are very large-scale. How long it will take to become less of a problem is indeterminate but surely not amenable to resolution in the short run.
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