Estonia and Latvia: Opposite approaches in the fight against HIV

In Eastern Europe two neighbouring countries are taking two very different approaches in their response to the rise in HIV amongst people who use drugs.

Whilst distribution of sterile needles and syringes, HIV testing and affordable treatment have helped reduce the number of new infections in Estonia, in neighbouring Latvia HIV transmission continues to grow. Researchers from both countries investigated how and why their HIV epidemics have taken different paths over the past two decades.

In the early 2000s, Estonia and Latvia had the highest rates of HIV incidence in the WHO European Region, along with Russia. Sharing syringes and lack of harm reduction measures were key reasons for the spread of infection.

From 2007 onwards the situations in Latvia and Estonia began to diverge. Estonia has seen the overall incidence of new HIV infections decrease by 61% and by a staggering 97% amongst men who inject drugs. Sexual transmission between men and women has also declined, although this was never the primary transmission path for the region. Over in Latvia, the incidence of new HIV infections continued to rise and by 2016 its rate was almost double that of Estonia – 35 per 100,000 versus 19 per 100,000.

At the same time, in both countries, the incidence amongst gay and bisexual men has increased, and the majority of heterosexual men with HIV were unaware of their status (52% in Latvia and 76% in Estonia – as of 2016 data).

By 2016, about 50% of people who inject drugs, and gay and bisexual men, in Estonia had been tested for HIV in the past 12 months, in Latvia testing rates remained low in all groups.

Key differences between the neighbouring states

In Estonia, a needle and syringe exchange program began in 1997, and by 2004 there were more than 20 such programs across the country. The distribution of needles and syringes increased from 500,000 in 2004 to about 2 million in 2016. Opioid substitution therapy (OST), which has been shown to reduce injecting drug use and HIV transmission, was also introduced in 2003.

In Latvia, the number of people receiving OST has remained relatively low. By 2014, fewer than 500 people a year were receiving OST. Although needle and syringe programs began in Latvia in 1997, the scale of services did not increase until 2008. In 2016, 94 needles and syringes were distributed in the country per drug user, compared to 224 needles per user in Estonia. Testing remained at a low level - less than 10% of people who use drugs were tested in the past 12 months - and antiretroviral treatment coverage was just 25% by 2016.

Until 2015, antiretroviral treatment was restricted to people with CD4 counts below 200 cells/μL despite WHO recommendations. The treatment and monitoring was only available via infectious diseases specialists in the capital of Latvia, Riga.

Conclusions

The study authors point out that in order to reduce the increase in HIV incidence in both countries, it is necessary to expand prevention programs through the introduction of PrEP and increase testing coverage for gay and bisexual men. Latvia also needs to expand its harm reduction programs, HIV testing and the provision of antiretroviral therapy for all – especially people who inject drugs.

Hope

On World AIDS Day 2020, the Estonian Network of PLHIV, EHPV, presented a film featuring actress Tatyana Kosmynina. The authors hoped that the participation of the famous actress would serve as an example for a tolerant attitudes and the promotion a positive attitudes in society towards people living with HIV.