HIV epidemic around the Baltic Sea

Transcription

1 HIV epidemic around the Baltic Sea Pauli Leinikki National Public Health Institute

2 Subtitles Statistics: what seems to have happened Dynamics: in what order Dissection: what actually happened Target friendly approach for interventions: why? HAART: hopes and challenges From case management to extended case management Future

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4 HIV/AIDS in Romania

5 AIDS in Romania

6 HIV cases in 2002 Country: Finland Russia St Peterburg Latvia Estonia Lithuania Cases/million inhabitants

7 HIV rates(% adults)* Country Ukraine Estonia Russia Spain Netherland UK s Finland Rate Country South Africa India China Thailand USA Mexico Haiti Rate

8 Kaliningrad Kaliningrad St. Petersb Russia /8 mo

9 The mosaic genome of the Kaliningrad strain LTR gag KAL153 pol env nef subtype A subtype B

10 Local outbreaks around the Baltic Sea Kaliningrad 1996 St. Petersburg I 1997 Riga 1997 St Petersburg II 1998 Helsinki 1998 Estonia east 2001 Estonia general 2003

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14 Reported HIV cases by age group in Nordic countries and Baltic states, HIV+ cases < <50 Age groups Nordic countries (N=2503) Baltic States (N=3594) EuroHIV

15 Characteristics of new HIV diagnoses in Baltic and Nordic countries, 2005 Countries HIV+ Per mln. % of young <25 % of female transmission mode Denmark % 26% MSM Finland % 29% Hetero Sweden % 42% Hetero Estonia % 37% IDU Latvia % 35% IDU Lithuania % 25% IDU

16 Rates of HIV per 10,000 pregnant women attending antenatal care in selected countries, HIV+ per 10,000 pregnant women Year Estonia Latvia Lithuania Finland Sweden

17 HIVprevalence among Intravenous drug users in several Baltic and Nordic countries 40 HIV prevalence (%) ,6 2, ,7 22 2,4 0 Denmark (2005) Finland (Helsinki, NEP, 2000) Sweden (Stockholm region prisons) Estonia (National, 2001) Latvia (National 2002) Latvia (Riga, 2002) Lithuania (National, 2003) Source: EuroHIV report Nr.70

18 IDUs are vulnerable to harm in many ways Multiple problems Medical Societal Indirect HIV/AIDS, Hepatitis

19 1200 Typical HIV outbreaks among IDU Annual incidence of HIV infection newly reported cases/million population 1000 I Example Incidence (log scale) Saturation

20 Risks associated to IDU: Spread of infectious diseases through sharing injection equipment (needles, syringes etc) Societal exclusion aggravated by discrimination Crime (to get the drugs) Accumulation of an ill prepared and excluded adult population into the society Undue hardening of societal norms

21 Hepatitis A in Finland Number of cases Tampere Year 2006

22 HCV seropositivity is strongly correlated with drug abuse in Finland: Proportion of seropositives: Risk groups: IDU 40 80% General population: Blood donors: <0.015% Health care workers: 0/567 Military recruits: 3/1063 Others: HIV positives 9% Prisoners: 28%

23 HIV and HCV infections among nonalcohol intoxicated drivers 1998 n Positive % HIV HCV (Leinikki, unpublished 1999).

24 Hepatitis C and time of injecting drug use Positive % Alle 1 v 1 2v 3 4v 5 7v 8 10v Yli 10v Time of injecting (years)

25 Opiate and ja amfetamine problem users (registry sampling resampling based estimates) (Partanen P. ym. 2004) Finland Capital area Opiate users Amfetamine Users

26 Drug users targeted information reach the population

27 Newly reported HIV cases among IDU 120 Annually reported cases Outbreak Year

28 Policy change implementation Network of Low Threshold Health Service Centers (LTHSC) for IDU in Finland 1997: 1 site in Helsinki Scale up of network coverage during Number Terveysneuvontapisteet of LTHSC

29 LTHSC in Finland Development of low threshold services targeted to IDU Hepatitis A & B epidemics HIV epidemic Infection risk project 1. LTHSC Government decision Change of vaccination program (HBV) Pharmacy recommendation Parlamentary policy paper Decision of the prosecutor New infectious disease statute legalising NEP Change of vaccination program (HAV)

30 Working principles of the Low Threshold Health Service Centers (LTHSC) for IDU in Finland: voluntary, not based on being drug free, personal information not recorded accessible to target group services include small scale health care provision, councelling & guidance to detoxification, VCT & HIVtesting, vaccinations (tetanus, HBV, HAV), condom distribution and exchange of injection equipment base for outreach work among IDU close collaboration with detox and primary health care services, social services and law enforcement

31 Injection equipment exchange at LTHSC : Working LTHSC Clients Visits Equipment exchanged ,1 milj. 1,4 milj. 1,8 milj. Equipment sold through the pharmacies:

32 Risk behaviour among Vinkki clients Pattern (sept 1) 1999 (Jun9) Has not borrowed S&N 55% 67% during the month Has lent to others 75% 44% Cleaned S&N after use 46% 89% High risk users 21% 3%

33 Tapauksia HIV Impact on HIV and Hepatitis epidemic in Finland Ruiskuhuumeisiin liittyvät HIV infektiot HCV Epidemia käynnistyi HCV ilmoitetut tapaukset (lähde : KTL INFE tartuntatautirekisteri) vuosi Number of LTHSC Terveysneuvontapisteet LTHSC network in Finland 21 municipalities > 30 sites 2004 statutory obligation for municipalities to provide services, Including inj.equipment exchange

34 Newly reported HIV cases in Finland (IDU) Annually reported cases Year

35 Hepatitis viral infections 1000 Hepatiitit Hep C Hep B

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37 Also ART is possible: HIV + IDU / Helsinki area n=227 Needs ART n= 99 No ART, CD4 > 200 n=128 ART + n=79 no ART CD4 < 200 n=20 Pia Kivelä 2/2004

38 Injecting in Finnish prisons 1999 Ever injected drugs? 128/ % Injected insided prison (ever) 66/128 57% during the last 4 weeks 28/66 52% shared eq. during last shoot 51/ % first injected inside prison 9/ % P.Holmstrom et al. National Public Health Institute 1999

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40 Impact of HIV in coinfections with HCV or HBV HCV/HIV: Singificant co morbidity, effect on LE, treatment interactions HBV/HIV:High virus production stage reemerges = rapid progress to LD

41 Case management: conventional Treatment of medical problems including medical prophylaxis of opportunistic infections Antiretroviral treatment Health promotion

42 Case management: comprehensive Medical CM including all aspects Social: employment, economic support, housing, education, child care, networking with peers etc

43 Case management: extended Medical CM Social CM Public Health CM: case finding, testing counceling primary and secondary prevention care of drug dependence, harm reduction rehabilitation rome care terminal care

44 Jonathan Mann 1985: AIDS is not just a disease of infected individuals. It very easily turns to a disease of the society. The symptoms of this disease are unjustified fears, oppression, violation of human rights and racism. We have seen the same symptoms in other contexts. Lets not let it happen again because of AIDS!

45 2005: AIDS is a disease of the society. It spreads through societal exclusion, discrimination, poverty, unrest and violence. Remedies include opennes, solidarity, nondiscriminating care, coherent family structures, societal and economic fairness

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