The HIV Epidemic is Expanding in Russia

In 2017, the Russian Federation (RF) is estimated to have the largest number of HIV-1 infected citizens of any country in Europe. Cumulative reported diagnoses reached over 1.16 million infections by mid-2017, and actual infections, including those that remain undiagnosed and/or unreported, are doubtless substantially higher. In contrast to the global epidemic pattern, the HIV epidemic in the RF and in most countries of Eastern Europe and Central Asia continues to expand significantly. Over 103,000 new HIV diagnoses were reported in the RF in 2016, a 5% increase in new infections over the previous year; reported HIV diagnoses had been increasing at some 10% per year from 2011–2016. Among Russian men aged 30–39 years of age, a group that has the highest male infection burden, some 2.8% were living with HIV infection in 2016. AIDS deaths, too, are rising and now negatively impact life expectancy. From January to June 2017, some 14,631 AIDS deaths were recorded, a 13.5% increase over the previous 6-month period. HIV/AIDS has risen to feature in the top 10 causes of premature death in the RF—a 35% increase from 2005. These realities should concern all who seek global control of the HIV pandemic, the researchers underscore, the results of their study were published in PLOS Medicine.

Despite the severity of this epidemic, including its scale, scope, and trajectory, remarkably little attention has been paid to the associated public health crisis in the international scientific literature. This may in part be due to the limited availability of data on HIV-1 in the RF that are presented and published outside Russia, and to the few international collaborations on HIV in the RF under the current administration. Therefore, the researchers reviewed publicly available data in the Russian language on HIV-1 in the RF through mid-2017 and analyzed Russian federal and province-level HIV policies and programs to assess the current burden of HIV-1 prevalence and incidence, the state of prevention programs as they relate to the epidemiology of HIV in the country, and policy impacts of current Russian laws, policies, and practices on the future trajectory of the epidemic.

The epidemiology of HIV in the RF after 3 decades of spread is complex and challenging to analyze. HIV burdens among MSM in the RF were reported to be in the 4%—6% range in 2012, yet a large respondent driven sample of some 1,300 MSM in Moscow found a prevalence of 15.6% (11.6% after RDS weighting) and reported that some three-quarters of these men were not previously aware of their HIV status and had not had recent HIV testing. These and other studies have consistently found higher burdens of HIV infection among key populations than what has been reported in the Russian surveillance and larger numbers of key populations. This suggests that many of those most at risk for HIV are not captured in the Russian national data and that these data are likely underestimates of the true burden. In 2014, Pokrovsky and colleagues from the Russian Federal AIDS Center suggested that only 51% of people living with HIV in the country in 2013 had been diagnosed with their infection. If generalizable and valid, this could bring the estimated cumulative number of HIV infections in the RF to more than 2 million.

HIV prevention measures have lagged markedly in the RF. This has been particularly true for the large population of PWID, since evidence-based drug treatment for opioid dependence is not available. The RF continues to ban any opioid agonist therapy, including prescription use of methadone and buprenorphine, despite these agents being on WHO’s essential drug list.

The passage of an antigay propaganda law in 2013 further restricted an already difficult environment for gay men and other MSM in Russia, also reducing prevention and treatment access for these men. After passage of the 2013 law, it became illegal to post or discuss information for gay men and other MSM, even on informational websites in Russia, further restricting information. Preexposure prophylaxis is not available, and treatment coverage for MSM is remarkably low, even in Moscow, where only some 9% of MSM living with HIV infection were found to be on antiretroviral therapy in 2014.

The RF is undergoing a severe, widespread, and geographically dispersed HIV epidemic. There is a very large 6-region cluster in Eastern and Western Siberia that is now the most affected part of this vast country. HIV prevalence and incidence are difficult to directly deduce from the available reporting data, but there is enough evidence to suggest that Russia’s epidemic is uncontrolled and worsening in 2017. It is disturbing that deaths are rising rapidly in an upper middle-income country that could, and should, be doing much better in the provision of prevention, treatment, care, and support for its citizens, especially those at high risk of HIV infection.

The continuous growth of the Russian HIV epidemic is a failure of public policy and practice. The current list of interventions with demonstrable efficacy in reducing HIV spread and improving treatment outcomes includes opioid agonist substitution therapy, needle and syringe exchanges, treatment as prevention, preexposure prophylaxis, and tailored interventions for key populations including PWID, MSM, sex workers, prisoners, and migrants. In the RF, all of these interventions are either not available or are unavailable at the scale necessary to control HIV. This is a true public health crisis and one that could largely have been avoided. Unless evidence-based prevention measures aimed at the most at-risk population groups are brought to scale in the RF, and unless access to treatment is significantly increased for all HIV-infected people, the likelihood of greater HIV incidence, and consequently greater AIDS morbidity and mortality, will only increase.